Primary Care Coding Alert

Minor and intermediate wound repair is a staple of many family practices: An 8-year-old boy falls off his bike on a dirt road, presenting with scrapes and several small lacerations; an elderly man slices open his forearm while using an electric hedge trimmer; a young woman sustains a long, shallow cut from a sharp edge on the aluminum bleachers at a local ball field.
      
Treatment for these and similar injuries may range from simple cleaning to debridement, to application of 2-octyl cyanoacrylate liquid adhesive (e.g., brand name Dermabond), to single or multilayered suturing. To optimize reimbursement, coders must understand several  codes and whether they are reported alone or with others.

 
When family physicians treat cuts, scrapes or open wounds that require cleaning but no extensive treatment, an office visit (99201-99215) is charged. The services include application of topical antibiotics and dressings like steristrips or butterfly bandages.
 
If debris is removed from the wound, soft-tissue debridement codes (11040-11044) are assigned. According to Wendy Walker, CPC, coding and chart auditor for Central Penn Medical Group in East Petersburg, Pa., this series describes wound care provided by a physician using sterile technique. Foreign material and devitalized tissue are excised, antibiotics may be applied, and the injury dressed. CPT 11040 is defined as debridement; skin, partial thickness, while subsequent codes identify debridement of successively deeper wounds. Medications and bandages are included in the fee schedule for the code.
 
Most often, an outpatient E/M code would not be reported in addition to the debridement code, Walker says, because an injury requiring immediate care is usually the only reason for the visit. On those rare occasions when a patient is seen for a truly separate condition, both codes may be reported. Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is appended to the E/M code. For example, if an 8-year-old boy fell from his bike on the morning of his annual checkup, the family practice may report the preventive office visit (e.g., 99393, periodic preventive medicine, established patient; late childhood [age 5 through 11 years]) with modifier -25, and 11041 (debridement; skin, full thickness) if time was spent cleaning the wound.

 
Walker says a lot of information must be processed in extensive wound-repair cases. Its important for coders to remind physicians that documentation must be very detailed to provide the information necessary for correct billing, she says.
 
She adds that when debridement and a repair are done together, coders should report only the relevant repair code because debridement is considered part of the overall service.
    
When more extensive wound repair requires staples, sutures or similar closure materials, coders must ask them-selves five questions to determine the correct code:

     
1. Can the repair be classified as simple, intermediate or complex? CPT organizes repair codes by complexity of the treatment. Simple repairs (12001*-12021) include superficial wounds of the epidermis or dermis and subcutaneous tissue, requiring one-layer closure. Intermediate repairs (12031*-12057) require additional layered closure of one or more deeper level of subcutaneous tissue or superficial fascia, excluding muscles. Complex repairs (13100-13160) are even more extensive and might include scar revision, extensive undermining, stents or retention sutures. In most cases, family physicians will perform simple and intermediate repairs, while complex treatment may be referred to another specialist, Walker says.

 
2. What part of the body is injured? The codes within the simple and intermediate categories are further characterized by location of the injury, she adds. For instance, 12001*-12006 refer to simple repairs on the scalp, neck, axillae, external genitalia, trunk and/or extremities. Codes 12051*-12057 describe intermediate repairs of wounds specifically to the face, ears, eyelids, nose, lips and/or mucous membranes.

 
3. How large is the wound? Once coders have determined the complexity of the repair and the site of the wound, they assign a specific code reflecting the length of the injury. A 9-centimeter cut on the leg requiring a simple closure, for instance, is reported with 12004 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 7.6 cm to 12.5 cm).
 
This is where a lot of problems arise, Walker says. Too often physicians dont clearly indicate the length of the wound in the notes. Proper coding depends on this information, so it is vitally important that this is communicated with the coder.

 
4. Are there multiple wounds? When patients have multiple lacerations of the same repair complexity on the same body part, the lengths of each wound would be added together. The code reflecting this total length would then be reported, Walker says. For example, if the patient had a 5-centimeter cut near his left ankle and a 9-centimeter cut on his left calf for a total of 14 centimeters,  12005 (12.6 cm to 20.0 cm) would be assigned for a simple repair, while 12035 would be reported for an intermediate repair.
 
If the lacerations are on different body parts or require different levels of repair, each relevant code is reported, appended with modifier -59 (distinct procedural service). A patient involved in a motor-vehicle accident, for instance, may sustain a 10-centimeter cut to her face and a 25-centimeter cut to her forearm, both requiring intermediate repair. 12054-59 is assigned for the facial laceration, while 12036-59 is used for the injured forearm. Similarly, if the facial wound required simple repair and the forearm intermediate repair, 12015-59 and 12036-59 are reported.

 
5. Was 2-octyl cyanoacrylate used to close the wound? Tissue adhesives, e.g., Dermabond, are relatively new on the scene and represent a different type of suture, says Quin Buechner, president of ProActive Consultants, a medical practice consulting firm based in Cumberland, Wis. This material acts like a disappearing suture. It is a liquid that is applied to relatively superficial wounds to hold the edges together and promote healing. Most often, it is used on small areas or in places where the physician wants to avoid marks from sutures -- like the face. Because it is painless to apply, it is often used on children.
 
Prior to 2000, CPT did not formally recognize tissue adhesives as an alternative to sutures or staples. However, introductory material in the 2000 manual clarified this issue by indicating wound closure can be achieved with suture, staples, or tissue adhesives (e.g., 2-octyl cyanoacrylate), either singly or in combination with each other, or in combination with adhesive strips.
 
As a result, Buechner says, family practices report use of tissue adhesives with the same codes as other repair techniques when submitting claims to private insurers. All the same rules apply, including reporting multiple lacerations and appropriate use of modifiers. He cautions, however, that an occasional insurer may not recognize liquid adhesives and may require an unlisted-procedure code like 17999 (unlisted procedure, skin, mucous membrane and subcutaneous tissue) accompanied by a report.
 
Medicare, on the other hand, requires that 2-octyl cyanoacrylate be reported with temporary HCPCS code G0168 (wound closure utilizing tissue adhesive[s] only). Because Medicare regards tissue adhesives as a simpler method of treatment, reimbursement for G0168 is much  lower than for simple laceration repair.
 
2-octyl cyanoacrylate should not be reported in conjunction with other codes describing similar wound care, Buechner adds. I had one physician tell me he sutures deeper layers of the wound and then uses tissue adhesive to close the surface layer, he says. It is not appropriate to bill for both. This constitutes one repair, and the intermediate code should be assigned. It is not different than if the physician used two types of sutures on one wound. The difference is only in the material; it is not an entirely different procedure.