Overview of surgical coding and wound repair

Surgical section

Specific guidelines and notes related to surgery coding must be considered when assigning a CPT code. Always review the current year’s guidelines for the Surgery section for the most up-to-date information. The following sections discuss a few of the more common guidelines. When coding procedures and services, be sure to read the guidelines and notes thoroughly for accurate coding assignment.

Surgical package definition

The CPT code set is designed to include patient prep, surgical care, and postsurgical care in a single code. These are considered global services because they are already built into the surgical package cost of the assigned CPT code. Medical coders who include any of these global services as a separate CPT code are committing fraud. The CPT code descriptions of global surgical services typically include the following:

• Local infiltration, digital block, or topical anesthesia
• After the decision for surgery, one related E/M encounter on the day of, or the day before, the date of the procedure
• Immediate postoperative care, including documentation in the patient’s health record and talking with family or other physicians
• Writing orders for postsurgical care
• Evaluating the patient in the post-anesthesia recovery area
• Typical postoperative follow-up care (includes care for approximately 6 to 8 weeks after surgery and is usually done at the provider’s office)

NCCI edits and unbundled codes

In 1996, in an effort to prevent fraudulent medical coding, the Centers for Medicare and Medicaid Services (CMS) established the National Corrective Coding Initiative (NCCI) edit list. This list contains two columns of codes, and the codes in the two columns are mutually exclusive. Submitted claims that contain mutually exclusive codes are automatically rejected.

When a CPT procedure is billed, this code includes services related to prepping the patient for the procedure, performing the procedure, and suturing to complete the procedure; the single code for the procedure is called a bundled code because it represents all of the stages of surgery. When each step of the procedure is listed separately, these are called unbundled codes. Unbundled codes are used when the components of a major procedure are separated and reported separately. When these codes are separated and used individually, a special report should be used to describe the circumstances that made the unbundling necessary; the reason for this is that unbundled CPT codes have higher reimbursements because each code is paid separately. Medical billers who regularly unbundle CPT codes may be cited for fraud or abuse.

Integumentary system: excision of lesions—benign or malignant

Excision of benign lesions includes a simple closure and local anesthesia. If a wound (incision, excision, or traumatic lesion) requires intermediate or complex closure, the repair by intermediate or complex closure is coded and reported separately from the incision or excision. For example, if the provider excised a benign lesion measuring 1 cm from the patient’s arm that required intermediate repair (closure), two codes would be used:

11401 – Excision, benign lesion including margins; excised diameter 0.6 to 1 cm

12031 – Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less

Levels of closure (repair)

• Simple repair: Performed when the wound is superficial (epidermis, dermis, or subcutaneous) without significant involvement of deeper structures. This includes local anesthesia and chemical or electrocauterization of wounds not closed.
• Intermediate repair: Includes simple repair with a need for a layered closure of one or more of the deeper layers of subcutaneous tissue and superficial fascia in addition to the skin closure. Single-layer closure of heavily contaminated wounds that required extensive cleaning or removal of particulate matter also constitutes an intermediate repair.
• Complex repair: Includes wounds that require more than layered closure (e.g., scar revision, extensive undermining, or stents or retention sutures). Necessary preparation includes creation of a limited defect for repairs or debridement of complicated lacerations. Complex repair does not include excision of benign or malignant lesions, excisional preparation of a wound bed, or debridement, or the removal of damaged tissue or foreign objects from a wound, an open fracture, or an open dislocation.

Listing services for wound repair

• The repaired wound or wounds should be measured and recorded in centimeters; it also should be indicated whether the wound was curved, angular, or in a starlike pattern.
• When multiple wounds are repaired, add together the lengths of those in the same classification (simple, intermediate, or complex) and from all anatomic sites that are grouped together into the same code descriptor.
• When wounds of more than one classification are repaired, list the more complicated repair as the primary procedure and the less complicated repair as the secondary procedure, using modifier –59.
• Debridement is considered a separate procedure only when gross contamination requires prolonged cleansing, when a large amount of dead or contaminated tissue must be removed, or when debridement is carried out separately without immediate primary closure.
• Wound repair that involves nerves, blood vessels, or tendons should be reported under the appropriate system for repair of those structures. The repair of these associated wounds is included in the primary procedure unless it qualifies as a complex repair, in which case modifier –59 applies.