Overview of surgical coding and wound repair

This chapter covers surgical package rules, National Correct Coding Initiative (NCCI) edits and unbundling, lesion excision, and wound repair coding. Specific guidelines and notes related to surgery coding must be considered when assigning a CPT code, so always review the current year’s guidelines for the Surgery section and read them thoroughly before assigning a code.

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 - the payer’s reimbursement for the primary procedure already accounts for this care, so billing it again as a separate code would double-bill for the same service. Medical coders who include any of these global services as a separate CPT code are committing fraud.

• 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 during the procedure’s assigned global period (0, 10, or 90 days), 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 Correct Coding Initiative (NCCI) edit list. NCCI procedure-to-procedure (PTP) edits pair a column one code (the comprehensive procedure) with a column two code (a component of that procedure); when both are billed for the same patient on the same date, the column two code is denied as bundled into the column one code unless the edit allows an appropriate modifier - such as modifier -59 - to show the two services were separate and distinct.

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. Reporting components of a major procedure separately requires supporting documentation - and, when appropriate, a modifier - to show the services were truly distinct from the primary procedure; billing components separately without that justification, simply to increase reimbursement, is 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.