Orthopedic Coding Alert

Question: Recently, a payer rejected a wound repair claim (12005) when our surgeon used a combination of stitches and adhesive strips. We carefully documented the wound length(s). What's the problem?

North Carolina Subscriber

Answer: Your payer may be confusing CPT's rules regarding tissue adhesive. Wound closure codes 12001-13160 "designate closure utilizing sutures, staples or tissue adhesive (for example, 2-cyanoacrylate), either singly or in combination with each other, or in combination with adhesive strips" [emphasis added], according to CPT. In other words, if the orthopedic surgeon applies any tissue adhesive or places a single stitch or staple, the wound care codes are appropriate. CPT does not differentiate among stitches, staples and tissue adhesive, and the coding does not change regardless of the surgeon's method of closure.
 
But if the orthopedist closes the wound using adhesive strips only, you may not report the repair/closure codes. Rather, as CPT specifies, "Wound closure utilizing adhesive strips as the sole repair material should be coded using the appropriate E/M code."

Note: The above guidelines apply to non-Medicare payers only. Medicare designates a special code, G0168 (Wound closure utilizing tissue adhesive[s] only), when you apply tissue adhesives only.

Your payer may be assuming that you used only adhesive strips, or perhaps misinterpreted the CPT rules to mean that any use of adhesive strips calls for an E/M service only. In either case, you should appeal the denial, carefully noting that the orthopedist used both adhesive strips and stitches to repair the wound.