COURSE DESCRIPTION. Page 1 of 18. Rev 3.0 February 2016

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1 COURSE DESCRIPTION Proper CPT wound repair coding is often a challenging process. The coder must first understand the various classifications of wound repair coding as well as the CPT manual s guidelines in coding these procedures. This continuing education course describes the different types of wounds and gives instructions on how to code these wound repair procedures accurately. Rev 3.0 February 2016 Page 1 of 18

2 COURSE TITLE: 2007 Update: A Guide to Wound Repair Coding Author: Virginia Escobedo, CPC, NCICS Program Director, Medical Billing & Coding Virginia Austin Number of Clock Hours Credit: 3.0 Course # P.A.C.E. Approved: Yes X No Upon completion of this continuing education module, the professional should be able to: 1. Name and describe five types of wounds. 2. Describe simple, intermediate, and complex repair of wounds as discussed in the CPT manual. 3. Identify CPT codes used for simple, intermediate, and complex repair of wounds. 4. Identify factors to take into account when coding for wound repair. 5. Identify when multiple wound repairs may be treated as one repair. 6. Identify when modifier 51 is attached to a CPT code for wound repair. 7. Given case studies, identify the CPT code(s) for wound repairs. Disclaimer The writers for NCCT continuing education courses attempt to provide factual information based on literature review and current professional practice. However, NCCT does not guarantee that the information contained in the continuing education courses is free from all errors and omissions. Page 2 of 18

3 INTRODUCTION The goal of all healthcare providers is to receive the maximum legal reimbursement for services provided while efficiently utilizing proper coding. Wound repair (closure) coding can sometimes be a challenge. There are several types of wounds in which the skin or tissue may be in need of repair: abrasions, lacerations, amputations, incisions, punctures and avulsions. A wound may include only one of these types or may include a combination of them. The definition of these wound types are: Abrasion the skin is rubbed or scraped off. Rope burns or rug burns are a few examples of an abrasion. This type of wound can become easily infected as dirt can be embedded into the wound. Laceration a ragged skin tear often made by a blunt object or machinery accidents. Lacerations sometimes have the added complication of the tissues being crushed due from the nature of the injury. These types of wounds are also prone to infection. Amputation nonsurgical removal of a limb. Bleeding is heavy and shock is common. In certain situations, the limb may be reattached surgically. Incision a wound from a sharp object; a cut. These types of wounds are least likely to become infected. Puncture a wound caused by a penetrating object that usually causes less surface damage than other wounds. Wounds made by nails and bullets are usually puncture wounds. If the nail or penetrating object has bacteria on it, infections may be common. Avulsion a tearing away of tissue from a body part. Bleeding may be heavy. It is possible that the torn tissue may be surgically reattached. The wound repair codes found in the Current Procedural Terminology (CPT*), surgery section, integumentary system subsection, are to be used only when the physician uses sutures, staples and/or tissue adhesives to close a wound. If the physician only uses adhesive strips to close the wound, the CPT directs the physician to use the appropriate evaluation and management code ( ). The more simple procedure would be billed an evaluation code rather than a procedure code. The physician may use adhesive strips in addition to these procedures, but he may not bill for a wound repair code that is found in the surgery section if adhesive strips are the only method utilized to close the wound. Page 3 of 18

4 It should be noted that Medicare is the only payer that uses a HCPCS code to report a simple repair using tissue adhesives (G0168). This is sometimes used in lieu of sutures. A good coder will always reference the CPT manual for notes and/or directions. The three types of classifications for the wound repair (closure) codes found in the surgery section of the CPT are simple, intermediate, or complex. Following are the CPT definitions of these classifications. *CPT is a registered trademark of the American Medical Association. CPT WOUND REPAIR CLASSIFICATION DEFINITIONS The CPT manual defines simple repair ( ) when the wound is superficial; eg, involving primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures, and requires simple one layer closure. This includes local anesthesia and chemical or electrocauterization of wounds not closed. In other words, this code is utilized for the simplest type of surgical wound repair on the integumentary system. Normal debridement (cleaning the skin tissue until normal tissue is viewed) and single-layered closure are included in a simple repair. In the documentation, the physician may bill for a simple repair by indicating in the medical record that the patient had a superficial wound that was repaired using sutures. Intermediate repair ( ) includes, in addition to the requirements of a simple repair, layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure. Single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair. In other words, an intermediate repair may be coded if the physician performed a layered closure or a single-layered closure that required extensive debridement. If the documentation shows that the physician performed a deep layered closure on the patient s wound using staples for the method of repair, then the physician would be able to use an intermediate repair code from the surgery section. Or, if the documentation reveals that the physician performed a single-layered closure only but he had to perform extensive debridement in addition to the single-layered closure, therefore going above and beyond normal debridement, the physician may bill for the intermediate repair code. Also, note that the physician does not need to specifically use the word intermediate in the documentation to bill for an intermediate repair. A layered closure constitutes an intermediate repair, therefore he may simply document that a layered closure was performed. Page 4 of 18

5 Complex repair ( ) includes the repair of wounds requiring more than layered closure, viz., scar revision, debridement (eg, traumatic lacerations or avulsions), extensive undermining, stents, or retention sutures. Necessary preparation includes creation of a defect for repairs (eg, excision of a scar requiring a complex repair) or the debridement of complicated lacerations or avulsions. Complex repair does not include excision of benign ( ) or malignant ( ) lesions. A complex repair code is the most complicated surgical repair that a physician will perform on the integumentary system. The physician would have to perform more than layered closure in order to bill for a complex repair. In addition, if the physician removed a benign lesion before he performed a wound repair procedure, then at least two surgical codes would be billed: one for the excision and one for the repair. INSTRUCTIONS All insurance companies go by the rule: If it is not documented, then it was not done. What this means is that even if a physician provided a high level of service to a patient, the physician does not get to bill for this level of service if the service is not documented appropriately. To obtain optimal reimbursement, detailed procedure information MUST be documented in the medical record. Sometimes, physicians forget to dictate seemingly insignificant information into the dictated letter that causes them to lose reimbursement. The physician knows what level of service he provided, but the documentation sometimes does not reflect this. When this occurs, optimal reimbursement is not being obtained. The first step in being a good coder is to educate the office staff and physicians that the more detailed information that is listed in the medical record usually results in greater reimbursement. One recommendation would be to have monthly meetings in which you go into detail about specific cases or examples in which you thought you could have billed for a higher level code if the required documentation was in the medical record. This method is usually quite effective and does not have to be time consuming for the busy physician. The factors that the coder needs to take into account when coding for wound repair ( ) are the anatomic site, the length of the wound and the type of repair. The CPT manual precisely states that wound repairs should be recorded in centimeters. When multiple wounds are repaired, it is possible to sometimes treat multiple repairs as one repair. You may add up the lengths of wounds from the same classification (simple, intermediate or complex) if the anatomic sites are grouped together in the CPT manual. This allows you to bill for multiple wound repairs using one CPT code. Page 5 of 18

6 Reference the CPT code below for the following scenario. You can observe that the CPT code groups together the scalp, neck, axillae, external genitalia, trunk, and/or extremities (including the hands and feet). The CPT groups these anatomic sites together because the techniques used to perform these repairs are similar. In other words, the procedures used to repair these anatomic sites are treated, according to the CPT manual, as the same procedure as long as the classification for the repair is simple. CPT Code Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm If the documentation states that the physician performed a simple repair of a 2.5 cm abrasion on the neck and a simple repair of a 3.4 cm laceration on the back, then the length of these wounds may be added up and billed as one simple repair. The two items to look at in this scenario: Is the wound repair classification the same? Yes, the physician performed a simple repair on both anatomic sites. Does the CPT manual group the anatomic sites together? Notice that code pertains to the scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet). Therefore, yes, the neck and trunk (back is part of the trunk) are grouped together. The CPT now directs you to add up the lengths of the simple repairs and code these two wound repairs as one: 3.4 cm cm = 5.9 cm. Because is a simple repair between 2.6 cm and 7.5 cm, then this is the correct code for this scenario. For the next scenario, some of the information will be the same as the previous scenario. The documentation in this scenario states that the physician performed a simple repair of a 2.5 cm abrasion on the lip and a simple repair of a 3.4 cm laceration on the back. Notice, the size of the wounds has not changed, but one of the anatomic sites has. What difference do you think this will make in the answer? Factors to look at before coding this case: Is the wound repair classification the same? Yes, the physician performed a simple repair on both anatomic sites. This is step one to allowing us to add up our wounds and code the repair as one CPT code. Does the CPT manual group the anatomic sites together? There is an abrasion on the lip and laceration on the back. Reference the following codes: Page 6 of 18

7 CPT Code CPT Code CPT Code CPT Code CPT Code Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm Lips and back are not grouped together. CPT code is the stand-alone code for scalp, neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet). CPT code is the stand-alone code for the face, ears, eyelids, nose, lips, and/or mucous membranes. Therefore, you are not allowed to add up the sum of these simple repairs. You are instructed to code them separately and (with modifier 51 added to this second code) are the correct codes for this case study. You may never add together the lengths of different classifications. In other words, you can not add together a 3.2 cm complex repair of the hand with a 7.2 cm simple of the hand. Even though they are the same anatomic sites, different classifications are always coded separately. When more than one classification of wounds is repaired, always list the more complicated procedure first. This stems from the rule to always code the most resource intensive reason for the visit first. A complicated wound is more serious, and therefore more in need of a repair, than a simple wound. It is also more time consuming. Page 7 of 18

8 Add modifier 51 to the secondary procedure to indicate that multiple procedures were performed. These rules will be demonstrated with the following example. The documentation states that the physician performed a 2.5 cm complex repair of the forearm and a much larger 10.7 cm intermediate repair to the forearm. The CPT directs you always to list the most complicated procedure first, and then the biggest repair would go next, and so on. Reference the following codes for this case study. CPT Code Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm CPT Code Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm The factors to consider when coding: Are the classifications that the physician performed similar? No, the physician performed a 2.5 cm complex repair of the forearm and a 10.7 cm intermediate repair of the forearm. Even though the physician operated on the same anatomic sites, the classifications are different. Therefore, the coder is not able to add up the length of the repairs. Which procedure should be listed first? The most complicated procedure that the physician performed was the 2.5 cm complex repair of the forearm. The CPT directs the coder to list the most complex repair first. Code is a complex repair of the arm; therefore, this code is listed first is an intermediate repair of the extremities between 7.6 cm and 12.5 cm; therefore, this code is listed second. Is modifier 51 needed? Yes. You are directed to add modifier 51 to the secondary procedure to indicate that multiple procedures were performed. o ANSWER: 13120, Page 8 of 18

9 CONCLUSION Debridement is not considered a separate procedure unless prolonged cleansing is required to remove the contaminated tissue, or if debridement is performed separately from the repair. In other words, debridement is usually considered part of the repair procedure. However, if a physician performs debridement on a day other than the wound closure procedure, then he may bill for the debridement. The CPT manual also states, For extensive debridement of soft tissue and/or bone, not associated with open fracture(s) and/or dislocation(s) resulting from penetrating and/or blunt trauma, see ( ) For extensive debridement of subcutaneous tissue, muscle fascia, muscle, and/or bone associated with open fracture(s) and/or dislocation(s), the coder is directed to reference codes ( ) The CPT manual differentiates between debridement procedures that are associated with fractures and/or dislocations and other debridement procedures that are not. The debridement codes are listed at the end of this course. In this next case study, the physician performed a 7.4 cm complex repair of a laceration to the chest that was grossly contaminated. The documentation revealed that the wound required prolonged cleansing in order to remove the contaminated tissue. The physician spent extra time cleaning the wound. Partial thickness debridement was performed. Reference the codes below. CPT Code Repair, complex, trunk; 2.6 cm to 7.5 cm CPT Code Debridement; skin, partial thickness In this case, due to the prolonged cleaning of the grossly contaminated wound, the physician is able to bill for the debridement in addition to the wound repair code. The physician would list the complex repair code first and the debridement code second with modifier 51 attached. o ANSWER: 13101, Page 9 of 18

10 A few more things to consider when coding for wound repair (closure) procedures: If the wound that is repaired involves nerves, blood vessels and tendons, the CPT manual directs the coder to report these procedures under the appropriate body system. For example, if a physician repairs a blood vessel in the heart, then the CPT manual directs the coder to go to the surgery section, cardiovascular subsection to find the correct code. The coder would not bill for this procedure in the integumentary system subsection. Simple ligation of vessels and simple exploration of nerves, blood vessels, or tendons is included in the wound repair procedure. Simple repair (closure) is bundled into the excision codes. If the physician excised a malignant lesion and performed a simple repair during the same operative session, the physician would only report the excision code. The simple repair is included in the excision procedure. Intermediate or complex repair is not included in the excision procedure and therefore may be billed separately. Use the following list of codes to answer the test questions. Page 10 of 18

11 Repair (Closure) 2007 CPT Codes 2007 CPT CODES DESCRIPTION SURGERY/INTEGUMENTARY SYSTEM Repair-Simple Sum of lengths of repairs for each group of anatomic sites Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less cm to 7.5 cm cm to 12.5 cm cm to 20.0 cm cm to 30.0 cm over 30.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less cm to 5.0 cm cm to 7.5 cm cm to 12.5 cm cm to 20.0 cm cm to 30.0 cm over 30.0 cm Treatment of superficial wound dehiscence; simple closure with packing SURGERY/INTEGUMENTARY SYSTEM Repair-Intermediate Sum of lengths of repairs for each group of anatomic sites Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less cm to 7.5 cm cm to 12.5 cm cm to 20.0 cm cm to 30.0 cm over 30.0 cm Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less cm to 7.5 cm cm to 12.5 cm cm to 20.0 cm cm to 30.0 cm over 30.0 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less cm to 5.0 cm cm to 7.5 cm Page 11 of 18

12 Repair (Closure) 2007 CPT Codes-continued 2007 CPT CODES DESCRIPTION SURGERY/INTEGUMENTARY SYSTEM cont. Repair-Intermediate cont. Sum of lengths of repairs for each group of anatomic sites cm to 12.5 cm cm to 20.0 cm cm to 30.0 cm over 30.0 cm SURGERY/INTEGUMENTARY SYSTEM Repair-Complex Reconstructive procedures, complicated wound closure. Sum of lengths of repairs for each group of anatomic sites. (For full thickness repair of lip or eyelid, see respective anatomical subsections) Repair, complex, trunk; 1.1 cm to 2.5 cm (for 1.0 cm or less, see simple or intermediate repairs) cm to 7.5 cm each additional 5 cm or less (List separately in addition to code for primary procedure) (Use in conjunction with 13101) Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm (For 1.0 cm or less, see simple or intermediate repairs) cm to 7.5 cm Each additional 5 cm or less (List separately in addition to code for primary procedure) (Use in conjunction with 13121) Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm (for 1.0 cm or less, see simple or intermediate repairs) cm to 7.5 cm each additional 5 cm or less (List separately in addition to code for primary procedure) (Use in conjunction with 13132) Repair, complex, eyelids, nose, ears and/or lips; 1.0 cm or less cm to 2.5 cm cm to 7.5 cm each additional 5 cm or less (List separately in addition to code for primary procedure) (Use in conjunction with 13152) Secondary closure of surgical wound or dehiscence, extensive or complicated (For packing or simple secondary wound closure, see 12020, 12021) Page 12 of 18

13 Excision--Debridement 2007 CPT Codes 2007 CPT CODES DESCRIPTION SURGERY/INTEGUMENTARY SYSTEM Skin, Subcutaneous and Accessory Structures Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin and subcutaneous tissues skin, subcutaneous tissue, muscle fascia, and muscle skin, subcutaneous tissue, muscle fascia, muscle and bone Debridement; skin, partial thickness skin, full thickness skin, and subcutaneous tissue skin, subcutaneous tissue, and muscle skin, subcutaneous tissue, muscle and bone Page 13 of 18

14 References (National Library of Medicine pictures) American Medical Association Current Procedural Terminology Standard Edition. Chicago, IL., page (wound repair definitions) pg&imgrefurl= nid=j1wvlnpkt6mnom:&tbnh=115&tbnw=93&prev=/images%3fq%3dabrasion%2bpi cture&start=2&sa=x&oi=images&ct=image&cd=2 (abrasion picture) Page 14 of 18

15 TEST QUESTIONS A Guide to Wound Repair Coding Course # Directions: Before taking this test, read the instructions on how to correctly complete the answer sheet. Select the response that best completes each sentence or answers each question from the information presented in the module. If you are having great difficulty answering a question, go to and select CE/Renewals, then select CE Update to see if course content and/or a test question have been revised. Code ONLY the wound repair codes. Modifier 51 is the only modifier that will be utilized for this test. 1. A four-year-old patient came into the emergency department after she fell off a swing and scraped her arm. The physician examined the abrasion and documented that she required a 4.3 cm simple repair on her left arm. a b c d A 52-year-old male patient slipped on a wet floor in a local restaurant. The patient collided with a bus boy, landed on a dirty fork, and cut himself on a broken plate. The restaurant manager recommended that the fork stay where it was to prevent heavy bleeding. The puncture wound measured 2.8 cm on his index finger. The patient also had a 3.4 cm laceration on his index finger from the broken plate. The physician performed a 2.8 cm intermediate repair on the patient s index finger and a 3.4 cm simple repair of the laceration on his index finger. Normal debridement was performed. a , b , c d Page 15 of 18

16 3. The patient got his finger caught in the car door when his brother accidentally shut the door on him. Part of the patient s right middle finger was hanging to the side. The patient s mother rushed him to the hospital after wrapping his finger in a tee shirt to help stop the bleeding. Patient was very distressed and in pain. The surgeon performed an immediate 7.5 cm complex repair to the patient s right middle finger to reattach the finger. a b , c , d A police officer suffered a series of knife wounds to the chest while on duty. The physician performed a 2.6 cm intermediate repair, a 5.2 cm intermediate repair, a 3.7 cm complex repair and an 8.4 cm simple repair. a , , , b , , c ,12034,12004 d , , A 6-year-old girl fell on a nail while her father was repairing a shelf in the garage. The nail is stuck in her right hand with minimal bleeding. The patient had a tetanus shot about 18 months ago. The physician performed a 1.2 cm intermediate repair to heal the puncture wound and applied an adhesive strip to a small abrasion on her forearm. a b c RT, d A 55-year-old woman came into the Emergency Department at 7:52 am with several lacerations on her chest and scalp. She was standing on a chair in the kitchen trying to reach the jelly jar at the top of the storage cabinet. The jelly jar broke and several pieces of glass were embedded in her wounds. The doctor irrigated the wound to remove all the debris before performing an 8.5 cm complex repair on the side of her chest and a 2.5 cm complex repair on her scalp. a , b , 13102, c , d x 2 Page 16 of 18

17 7. A 25-year-old female patient was injured in a motor vehicle accident when she lost control of her car and ran into a tree. The physician performed a 3.7 cm complex repair to her upper lip, a 10.5 cm complex repair to her cheek and a 4.2 cm intermediate repair to her thigh. a , ,12031 b , , c , 13133, , d , , , A construction worker fell 1½ floors while building a house. He landed on a bed of nails, plywood and other debris. He had several lacerations to his arms, chest and face. The physician repaired a 5.9 cm complex repair to his chest, an 8.2 cm complex repair to his arm, a 4.9 cm intermediate repair to his cheek and a 2.5 cm intermediate repair to his lip. Because of the gross contamination of the wounds, the physician performed a prolonged cleansing using partial thickness debridement. a , 13101, , b , , 11041, c , 13122, , , d , , , A 28-year-old woman was plucking her eyebrows while at a stop light on the highway. A car going about 30 miles per hour hit her from behind. She suffered a 4.2 cm laceration to her forehead. The physician performed an intermediate repair. The physician is uncertain if the patient will sustain a scar so a referral was made to a plastic surgeon. a b c , d , A young boy was skateboarding down the long stone stairs at the Capital Building, and wounded himself when his board flipped to the side. The patient was going quite fast and suffered a serious abrasion to his nose and his arm. The physician performed a 7.6 cm complex repair to his nose and a 7.4 cm intermediate repair to his knee. a , b , 13153, c , d , 12046, Page 17 of 18

18 11. A 43-year-old woman was hurt at work while using a box cutter to open a package. Patient was ordered by her work to go to the Emergency Department to have her incision evaluated. The physician performed a 1.7 cm one-layer closure on her left hand. a b c d A 14-year-old male patient was dared by his friends to jump from his home s room to his neighbor s roof. He was knocked unconscious and received several lacerations and abrasions to his chest, face, head, and legs. He was rushed to the Emergency Department where he was evaluated by a physician. The physician performed a 9.5 cm complex repair to his scalp, a 7.5 cm complex repair on his chest, a 3.4 cm intermediate repair on his lip, an 8.4 cm intermediate repair on his left leg, and a 5.5 cm intermediate repair on his right leg. a , 13122, , , b , , , c , , , d , 13133, , , *End of Test* Page 18 of 18