Wiki Confused when Closure is allowed: Open Fx + Exploration.

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bmeech

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I see several articles on this issue, but still a bit confused. Dr. submitted Open ORIF (27759) + I&D to Bone (11012) + Exploration (20103), All the Same area. He states he is allowed to bill for Closure of this Open Fracture.
My thoughts: the Column 2 =20103 bundles with Column 1=11012, a 59 would not be allowed (same area). or if using closure code 13132 Becomes the Column 1 code and the 11012 Becomes the Column 2 code (?) I don't understand that. Article states "20103: Billable If wound required Enlargement...But the I&D + the reduction of the Fx was done through this extension. Then another article states "Closure will always bundle with debridment except if extensive undermining ( 20103 or 13132)?https://www.aapc.com/blog/26267-closure-coding-made-simple/ & https://www.aapc.com/blog/29508-removal-of-foreign-body-included-in-wound-explorations/

Thank you for your help as I work through my Friday morning brain.
 
Good Morning,
Just happened to see this question, I would suggest you review the NCCI policy manual carefully, it's pretty well laid out [ https://www.cms.gov/files/document/medicare-ncci-policy-manual-2023-chapter-4.pdf ] . Also, in regards to exploration 20103, same thing, review the guidelines prefacing these codes, specifically, basically when you an exploration code you can't code repairs made (that's very simply put, but I am in a bit of hurry). OH - remember to use your open fracture debridement code 11010-11012, this is probably what he is trying to get compensated for... I hope this helps !​
 
Depending on the documentation you would want one of these CPT 11010-11012 (as suggested) for debridement at the site of an open fracture or dislocation. If he went down and included bone, you can report that with the ORIF. The exploration would not be separately reportable with these, it has separate procedure designation and could only be reported if it was done at a different anatomical location (like maybe the bullets hit the other leg too for example but no fx). See the glossary (Appendix K) of the CPT book for separate procedure info. Also, agree, look at Chapter 4 of NCCI manual.
Closure is included.
 
Side note - if they left the wound open for some reason (too swollen to close, risk of compartment syndrome, or major contamination maybe) then you would be looking at secondary closure later (13160) which would be reportable. But, if they did primary closure it's no.
 
Thank you everyone, I know that the ORIF + 11012 is allowed, my concern was his Exploration ( 20103) and the Dr. stating he is "Allowed bill for to Closure all of his Open Fx treatments" ( even after he "extends" the wound) that did not seem right to me and the confusing part of the articles around 20103. I did send him the guidelines, but he is insisting I am wrong...needed some back up power, Thanks for sharing yours
amyjph said:
Depending on the documentation you would want one of these CPT 11010-11012 (as suggested) for debridement at the site of an open fracture or dislocation. If he went down and included bone, you can report that with the ORIF. The exploration would not be separately reportable with these, it has separate procedure designation and could only be reported if it was done at a different anatomical location (like maybe the bullets hit the other leg too for example but no fx). See the glossary (Appendix K) of the CPT book for separate procedure info. Also, agree, look at Chapter 4 of NCCI manual.
Click to expand...
 
I think it is going to depend on the documentation of each individual case. He "might" report in a very slim # I think. If the wound was extended, there was extensive undermining not included in the 11012, and it has to be very, very clearly documented. It is very confusing, I agree. If you read the guidelines in the integumentary section in CPT, it gives instructions right before the repair section. There are CPT Assistant articles, but I don't have access right now, I am sure there's one or two that would answer this. There are also very specific guidelines at the front of the section on wound exploration if you read CPT. Also, with CPT Assistant info. Your best bet is to check CPT Assistant too. It can get very complicated if you are talking major, multi-trauma with a lot of gunshot wounds or something like that or a big trauma case with many injuries and fractures throughout the body.

NCCI Manual Chapter 1: https://www.cms.gov/files/document/medicare-ncci-policy-manual-2023-chapter-1.pdf
Some services are integral to large numbers of procedures. Other services are integral to a more limited number of procedures. Examples of services integral to a large number of procedures include:
• Surgical approach including identification of anatomical landmarks, incision, evaluationof the surgical field, debridement of traumatized tissue, lysis of adhesions, and isolationof structures limiting access to the surgical field such as bone, blood vessels, nerve, andmuscles including stimulation for identification or monitoring
• Surgical closure and dressings

Chapter 3: https://www.cms.gov/files/document/medicare-ncci-policy-manual-2023-chapter-3.pdf
9. Closure/repair of a surgical incision is included in the global surgical packageexcept as noted below. Wound repair CPT codes 12001-13153 shall not be reported separately todescribe closure of surgical incisions for procedures with global surgery indicators of 000, 010,090, or MMM. Simple, intermediate, and complex wound repair codes may be reported withMohs surgery (CPT codes 17311-17315). Intermediate and complex repair codes may bereported with excision of benign lesions (CPT codes 11401-11406, 11421-11426, 11441-11471)and excision of malignant lesions (CPT codes 11600-11646). Wound repair codes (CPT codes12001-13153) shall not be reported with excisions of benign lesions with an excised diameter of0.5 cm or less (CPT codes 11400, 11420, 11440).


 
Forgot to add, make sure you always check the dates on articles you are researching and referencing. The ones you linked are from 2013 and 2015. CPT, NCCI, and other official guidance changes. Reading old info is good but you have to keep the dates in mind.
 
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