Size and repair complexity are keys to wound coding

Here are CPT coding guidelines

(Editor’s note: Beginning with this issue, Wound Care offers a new feature that provides you with the information you want most. Send your questions to us, and we’ll find professionals to provide the answers. See note at the end of this article for contact information.) 

This response is from Rita A. Scichilone, MHSA, RRA, CCS, coding consultant with Professional Management Midwest in Omaha, NE. 

Question: I work at a large physician group and the coders constantly have problems with coding for wound care. Can you provide us with some guidelines? 

Answer: To accurately code wound repairs in CPT, the coder must have the size of the wound and the complexity of the repair documented, or the code will not be accurate. CPT classifies wounds as simple, intermediate, or complex, and breaks down each category by the size of the wound into the appropriate code. 

Wound lengths within the same site classification and complexity are "summed" — in other words, the lengths are added together to choose the right code. 

The following definitions apply: 

• Simple repair — This is a superficial wound that involves only the skin and/or subcutaneous tissue. This type of wound is closed with simple sutures, or it may be closed with adhesive strips. In the case of a closure with butterfly bandage or steristrips, no CPT procedure code is assigned; rather, an evaluation and management code appropriate to the site of service is used. These fall into the CPT code range 12001 to 12108. 

• Intermediate repair — This group of codes is used to report repair of wounds that require layered closure. This occurs when deeper tissues below the subcutaneous tissue, such as fascia and/or muscle, are involved in the wound. These tissues require separate closure in addition to suture of the skin. Intermediate repairs fall into the CPT code range 12031 to 12057. 

• Complex repair — These codes are used to report wound repairs requiring reconstructive surgery, skin grafting, and other complicated wound closure requiring time-consuming techniques to obtain the desired results. 

Coding wound repairs is simple if you take the following steps: 

1. Measure the wound in centimeters. 

2. When multiple wounds are repaired, add together the lengths of those in the same classification and report them as a single code. When more than one classification of wounds is repaired, list the more complicated as the primary procedure and the less complicated as the secondary procedure. Add modifier 51 for multiple procedures performed during the same operative session. 

3. Decontamination and debridement should be coded separately only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized tissue are removed, or when debridement is carried out separately, without immediate primary closure. 

4. If the wound repair involves nerves, blood vessels, or tendons, choose codes from those sections of the CPT surgical section first. 

Often after excision of lesions, a residual defect may require layer closure. Primary closure is included in the excision of lesion codes, but when layer closure is required, it is appropriate to report a code from the range of 12031 to 12057. 

Earlier this year, the Health Care Financing Administration seriously considered a proposal to bundle both intermediate and complex repairs into the excision codes for Medicare patients and redistribute the RVUs for these codes. Instead, HCFA will continue to allow physicians to report intermediate and complex repair codes separately, but it will no longer follow the CPT definition of simple and intermediate repairs. Medicare adopted these definitions to reduce the misuse of intermediate repair codes. 

HCFA’s definition of these repairs, implemented Jan. 1, 1997, is as follows: 

1. Simple closure involves skin and subcutaneous tissue. 

2. Intermediate repair is to be used for closure of one or more of the deeper layers of fascial layers, in addition to skin and subcutaneous tissue. 

3. Complex repair remains as described in CPT. 

[Editor’s note: Send questions you would like to see answered in future columns to: Wound Care, P.O. Box 740056, Atlanta, GA 30374. Or you can fax them to Managing Editor Glen Harris at (404) 261-3964 or e-mail us at glen_harris@medec.com.]