Find three important details in the report, and you’ve got the case all sewn up.
by G.J. Verhovshek, MA, CPC
When coding for wound repair (closure), you must search the clinical documentation to determine three things:
- The complexity of the repair (simple, intermediate, or complex)
- The anatomic location of the wounds closed
- The length, in centimeters, of the wound closed
Each of these variables is specified in the repair CPT® code descriptors. For example:
12013 Simple repair of superficial wounds [complexity] of face, ears, eyelids, nose, lips and/or mucous membranes [location]; 2.6 cm to 5.0 cm [length]
12035 Repair, intermediate [complexity], wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet) [location]; 12.6 cm to 20.0 cm [length]
13150 Repair, complex [complexity], eyelids, nose, ears and/or lips [location]; 1.0 cm or less [length]
Complexity Comes First
First, determine the complexity of the performed repair(s). Your CPT® codebook is the definitive source, providing full definitions for each type of repair:
“Simple repair is used 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.”
Simple repairs are—as the name indicates—fairly straightforward, and require only single-layer closure of the affected area. Such repairs involve only the skin; deeper layers of tissue are unaffected. By contrast:
“Intermediate repair … require[s] one 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.”
In other words, wounds requiring intermediate repairs are deeper than those requiring simple repair. Per CPT®, some single-layer closures may qualify as complex repairs, if the wound is “heavily contaminated” and requires “extensive cleaning or removal of particulate matter.”
When searching documentation for clues as to the complexity of repair, statements such as “layered closure,” “involving subcutaneous tissue,” and/or “removal of debris,” “extensive cleansing,” etc., point to an intermediate repair. Lack of these details, or a statement of “single layer closure,” suggests a simple repair.
Complex repairs involve wounds that are deeper and more dramatic, which may require debridement or significant revision:
“Complex repair … require[s] 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 limited defect for repairs or the debridement of complicated lacerations or avulsions.”
An operative note detailing such an extensive, reconstructive repair should be easily distinguished from other repair types, due to the need for procedures well beyond cleansing and suturing at one or more levels.
Second, Choose a Location Subcategory
After you’ve determined if the repair is simple (12001-12018), intermediate (12031-12057), or complex (13100-+13153), narrow your code selection by the documented location of the wound(s) repaired. This is best done by referring to the CPT® code descriptors. For instance, intermediate repairs are grouped into anatomic categories:
12031-12037: scalp, axillae, trunk, and/or extremities (excluding hands and feet)
12041-12047: neck, hands, feet, and/or external genitalia
12051-12057: face, ears, eyelids, nose, lips, and/or mucous membranes
Third, Size Seals the Deal
Per CPT®, “The repaired wound(s) should be measured and recorded in centimeters, whether curved, angular, or stellate [star shaped].” With this final piece of information, you can choose a repair code.
Example 1: For an intermediate repair (12031-12057) of a leg wound (12031-12037, extremities) measuring 10 cm, you would select 12034 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm.
Example 2: A plastic surgeon performs a complex repair of a facial laceration, measuring 2.5 cm. Because this is a complex repair, begin with code set 13100-+13153. The complex repair codes are relatively precise regarding location, and differentiate between wounds of the eyelids, nose, ears, and/or lips and those of the forehead, cheeks, chin, mouth, and neck. If the physician documented only “facial laceration,” ask for more detail. For this example, assume the wound was on the patient’s left cheek. This allows you to narrow your code choice to 13131-+13133. Because the wound was 2.5 cm long, the correct choice is 13131 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm.
Note: Complex repair codes (unlike either the simple or intermediate repair codes) employ add-on codes to describe wounds greater than 7.5 cm. Report as many units of the add-on codes as necessary to describe the size of the wound repaired.
Returning to Example 2, the 2.5 cm repair is reported 13131. If the wound had been 3.5 cm long, the proper code would be 13132 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm. If the wound had been 10 cm long, proper coding would be 13132, describing the first 7.5 cm, and +13133 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less (List separately in addition to code for primary procedure) to account for the remaining 2.5 cm. If the wound had been 16 cm long, proper coding would be 13132 and 13133 x 2 (7.5 cm + 5 cm + 3.5 cm), and so on.
Code Multiple Repairs
Often, the clinician may repair several wounds in a single session. When this occurs, determine the proper coding for each repair individually. Then, check if any repairs of the same complexity are grouped to the same anatomic areas. If so, you should add together the lengths of the similar wounds and report them using a single, cumulative code. “For example,” CPT® says, “add together the lengths of intermediate repairs to the trunk and extremities.” Do not combine wounds of different severity or those that fall within separate anatomic locations (as defined by the relevant code descriptors).
When reporting several wounds of differing severity and/or location, claim the most extensive (i.e., highest-valued) code as the primary service, and append modifier 59 Distinct procedural service to subsequent repair codes. Multiple procedure reductions will apply for the second and subsequent procedures (except for those procedures reported using an add-on code).
Example 3: The physician repairs four wounds for a patient involved in a fall from a motorcycle:
- Simple repair, 10 cm, left arm
- Intermediate repair, 12 cm, left arm
- Intermediate repair, 15 cm, left leg
- Complex repair, 9.0 cm, left leg
There is a single simple repair, which is reported with 12004 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm.
The complex repair is also the only one of its type, and is coded 13121 Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm for the initial 7.5 cm, along with +13122 Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure) for the additional 1.5 cm (7.5 cm + 1.5 cm = 9 cm).
There are two intermediate repairs: Considered separately, you would report them using 12034 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm and 12035 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm. Notice, however, that although these are separate wounds, both require intermediate repair, and both are located within the same anatomical category (the extremities). As such, combine the two wounds (12 cm + 15 cm = 27 cm) to report 12036 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cm.
The complex repair is the most extensive procedure and should be first listed. The remaining repairs are reported with modifier 59 appended. Final coding:
13121, +13122
12036-59
12004-59
Multiple procedure reductions will apply to 12036 and 12004 (but not to the primary procedure, or + 13122).
Don’t Shortchange the Physician
Detailed physician documentation is critical to determine the complexity and size of the repair(s). Lackluster notes can dramatically affect both coding precision and the physician’s bottom line, as the payment difference between the various repair types is significant. For example, for a small (2.0 cm) chest wound:
- A simple repair (12001 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less) is valued at 0.84 physician work relative value units (RVUs), for an approximate Medicare payment of $21.
- An intermediate repair (12031 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less) is valued at 2.0 physician work RVUs, for an approximate Medicare payment of $50.
- A complex repair (13100 Repair, complex, trunk; 1.1 cm to 2.5 cm) is valued at 3.0 physician work RVUs, for an average Medicare payment of $75.
Source: RVUs and calculated average Medicare payments are from the 2013 National Physician Fee Schedule Relative Value File. Actual Medicare payments vary by geographic location. Private payer reimbursements are determined by contract.
Look out for documentation that lacks relevant detail. If necessary, meet with your physicians and show them the code descriptors, so they know precisely which details are required to code correctly (and to collect all earned payments).
Sidebar
Wound Repair: What’s Bundled, What’s Not
Wound repair (closure) may be performed with other, related procedures during the same session. Some of these related procedures may not be separately reported; others may be separately reported, or separately reported only in specific circumstances. Here’s a quick rundown, based on CPT® and the Medicare guidelines.
Never reported separately with wound repair/closure:
- Any/all services considered part of the global surgical package (e.g., topical anesthesia, writing orders, immediate/typical postoperative care, etc.) See the Surgical Package definition in the CPT® Surgery Guidelines for complete details. Note that Medicare defines the surgical package differently than does CPT®. See Medicare Claims Processing Manual, chapter 12, section 40.1.
- Chemical or electrocauterization of wounds not closed
- Simple ligation of vessels in an open wound
- Simple exploration of nerves, blood vessels, or tendons exposed in an open wound. More complex exploration may be reported separately (see below).
- For complex repairs, “creation of a limited defect for repairs or the debridement of complicated lacerations or avulsions”
Sometimes reported separately with wound repair/closure:
- Decontamination or debridement: CPT® specifies, “Debridement is considered a separate procedure only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when debridement is carried out separately without immediate primary closure.” [emphasis added]
- Wound repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions, but lesion excision may include would repair. Per CPT®, simple repairs are always included in lesion excision, but “Repair by intermediate or complex closure should be reported separately.” Medicare, via National Correct Coding Initiative edits, follows the same rules.
Always reported separately with wound repair/closure:
- When associated with complex repairs (13100-+13153), excisional preparation of a wound bed (15002-15005), or debridement of an open fracture or open dislocation
- Complex repair of nerves, blood vessels, and tendons
- Per CPT®, “If the wound requires enlargement, extension of dissection (to determine penetration), debridement, removal of foreign body(s), ligation or coagulation of minor subcutaneous and/or muscular blood vessel(s) of the subcutaneous tissue, muscle fascia, and/or muscle, not requiring thoracotomy or laparotomy, use codes 20100-20103 as appropriate.”
G.J. Verhovshek, MA, CPC, is managing editor at AAPC.
