Kevinph84
Guest
Hello Everyone,
I was wondering if I could get some help for a case. Would you report the below procedure as CPT 11042 and 12032? If so, since NCCI states 11042 is included intermediate repair, would you only report 12032? Could modifier -59 be applied to bypass the edit?
Or would you perhaps report this encounter using the skin lesion excision codes with an intermediate repair? Or could this perhaps fall into scar revision, and be reported by a single complex repair code? I'm confused!
The provider did state he performed a "complex" repair, but the documentation only supports an intermediate repair (if seperately reportable). That is unless the entire encounter falls under the "scar revision" concept.
PREOPERATIVE DIAGNOSIS & POSTOPERATIVE DIAGNOSIS:
NONHEALING ULCER INVOLVING THE LEFT CHEST WALL STATUS POST MASTECTOMY.
PROCEDURES:
WIDE EXCISION OF A NONHEALING ULCER AND WITH A COMPLEX REPAIR.
OPERATIVE PROCEDURE: Under adequate mild local anesthesia and sedation, the area being prepped and sterilely draped, a curvilinear incision was made to remove the portion of the old transverse scar and also to remove the nonhealing sinus tract. We carried out dissection through the skin and subcutaneous tissue and down to the pectoralis muscle. The lesion that was removed was about 7 cm x 4 cm x 2 cm. Once the lesion was removed, we irrigated and we coagulated all the bleeders. The deep subcutaneous layer was closed with a 2-0 Vicryl, the superficial with 3-0, and the skin was closed with 3-0 nylon. Blood loss was minimal. Fluid replacement was in the form of electrolyte solution. A bulky pressure dressing was applied. The patient tolerated the procedure well.
I was wondering if I could get some help for a case. Would you report the below procedure as CPT 11042 and 12032? If so, since NCCI states 11042 is included intermediate repair, would you only report 12032? Could modifier -59 be applied to bypass the edit?
Or would you perhaps report this encounter using the skin lesion excision codes with an intermediate repair? Or could this perhaps fall into scar revision, and be reported by a single complex repair code? I'm confused!
The provider did state he performed a "complex" repair, but the documentation only supports an intermediate repair (if seperately reportable). That is unless the entire encounter falls under the "scar revision" concept.
PREOPERATIVE DIAGNOSIS & POSTOPERATIVE DIAGNOSIS:
NONHEALING ULCER INVOLVING THE LEFT CHEST WALL STATUS POST MASTECTOMY.
PROCEDURES:
WIDE EXCISION OF A NONHEALING ULCER AND WITH A COMPLEX REPAIR.
OPERATIVE PROCEDURE: Under adequate mild local anesthesia and sedation, the area being prepped and sterilely draped, a curvilinear incision was made to remove the portion of the old transverse scar and also to remove the nonhealing sinus tract. We carried out dissection through the skin and subcutaneous tissue and down to the pectoralis muscle. The lesion that was removed was about 7 cm x 4 cm x 2 cm. Once the lesion was removed, we irrigated and we coagulated all the bleeders. The deep subcutaneous layer was closed with a 2-0 Vicryl, the superficial with 3-0, and the skin was closed with 3-0 nylon. Blood loss was minimal. Fluid replacement was in the form of electrolyte solution. A bulky pressure dressing was applied. The patient tolerated the procedure well.
