Tie Up the Loose Ends of Surgical Wound Coding

By Terri Brame, MBA, CHC, CPC, CPC-H, CGSC, CPC-I
Surgical wound closure can be confusing and vague, but you can sew up your wound closure knowledge by returning to the basics. CPT® foundation concepts always apply and can help you navigate wound closure and delayed closure procedures.

Define Your Terms

Keep the definitions of primary, delayed primary, and secondary in mind when you code for wound closures:

• Primary closure – Actively closing a wound immediately after completing the procedure with sutures, Steri-Strips, or another active binding mechanism.
• Delayed primary closure – Actively closing a wound, but at a later operative session beyond the procedure.
• Secondary closure – Usually means allowing the wound to close without intervention (without suture or other closure); however, when active wound closure is described as “secondary,” the term is used in place of delayed primary closure.

Primary Closure – What’s Included?

The wound closure portion of a global surgical package involves smaller procedures. Any typical procedure required to close the surgical wound is bundled with the primary procedure.
Some repair level—simple, intermediate, or complex—always is included as part of the wound closure. For laparotomies and sternal thoracotomies, the code assumes the surgeon will close this major incision, and with rather complex closure.
For example, because ventral/incisional hernia repair (49560-49566) principally is the closing of an opening in the abdominal wall, these repairs are included as part of a larger procedure unless they are noted to be in a separate anatomic location. If some debridement is necessary to reapproximate the skin for a good result, the debridement is bundled into the primary procedure, as well.

Primary Closure – Additional Procedures

When wound closure is more extensive than typical, additional procedures may be reported. For example, flaps may be necessary to close a large wound. When this occurs, a variety of flaps may be used, and you may separately report the flap. Common flaps for a laparotomy include 15734 Muscle, myocutaneous, or fasciocutaneous flap; trunk and 15756 Free muscle or myocutaneous flap with microvascular anastomosis.
If the surgeon determines additional material is required to close the wound properly, recall CPT® coding basics before selecting a code. When laparotomy requires additional material, it might be tempting to choose +49568 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair). Notice, however, the parenthetical comment below 49568—you may add this code to 11004-11006 and 49560-49566 only.
When the material used is a bioprosthetic, such as Alloderm®, you might think a code from the 15002-15431 series is correct, but those codes don’t apply to this procedure. CPT® is an organ system-based coding system. This code series is for skin replacement surgery and skin substitution. CPT® codes are procedure-based, not product-based. When the surgeon closes a wound and uses a bioprosthetic as a fascial graft, the graft is not intended to replace skin, so these codes are incorrect.
There is not an exact code to report when the surgeon uses additional material to close the myofascial layers of a wound so CPT® basics apply. Some codes may bundle these grafts into the primary procedure surgical package. This is likely when the graft is a typical part of the closure and is common practice. Otherwise, report the graft with an unlisted procedure code, such as 20999 Unlisted procedure, musculoskeletal system, general.

Delayed Primary (Secondary) Closure

It is easy to be confused by the term “secondary.” You may think a secondary closure requires a previous closure to be performed. Secondary does not necessarily mean second with regard to wound closure, however. In this context, secondary denotes either delayed primary closure or a subsequent closure following an initial closure procedure.
If the surgeon performs a procedure that typically includes wound closure, but decides not to perform closure during the primary procedure, report the primary procedure code with modifier 52 Reduced services. The modifier is necessary because the surgeon did not complete the entire intra-operative portion of the surgical package. When the surgeon finally performs the closure, report the closure with modifier 58 Staged or related procedure or service by the same physician during the postoperative period appended because the surgeon planned to close the wound.
Before selecting a secondary wound closure CPT® code, be sure a more comprehensive code is not correct.
For example, a laparotomy has been packed open to allow for lavage due to peritoneal infection. During the fifth washout, the surgeon unpacks the wound, explores the peritoneal cavity, completes lavage, and determines the infection has cleared. The wound is closed with layered sutures. The intra-operative portion of the surgical package for 49002 Reopening of recent laparotomy includes exploration and lavage. In this instance, rather than reporting a closure-only code, 49002 is appropriate.
If a more comprehensive code does not apply, consider using 13160 Secondary closure of surgical wound or dehiscence, extensive or complicated. Although some reference materials only apply this code for infection or dehiscence, secondary closure of surgical wound is the first part of the code’s long description. The short description for this code is “Late closure of a wound.” The long description of 13160 is an instance where “secondary closure” is a replacement term for “delayed primary closure.”

Closure for a Reopened Wound

Report 13160 also for wound dehiscence closure. If, however, the surgical wound is a laparotomy that has dehisced (split open), you should consider 49900 Suture, secondary, of abdominal wall for evisceration or dehiscence.
Code 13160 includes closing a wound in multiple layers without reopening the wound. Code 49900 includes reopening the entire wound, removing any remaining sutures, and completely resuturing the wound. The latter code also includes replacing any structures that moved through the opening back into the abdominal cavity. If the surgeon completes any additional work within the abdominal cavity, such as exploration, lavage, or repair, consider whether 49002 or another abdominal code is more appropriate.
Codes 12020-12021 are for much simpler wounds that have dehisced and may not be infected. Code 12020 Treatment of superficial wound dehiscence; simple closure only includes single layer closure. If the repair includes layered closure, 12020 is not correct.

Capture All Reportable Services

Never rule out using an unlisted code to report the procedure performed. Remember the CPT® axiom is to select only a code that represents the exact procedure performed. Many surgeons complete extremely large wound closures and reclosures after significant trauma or infection. These closures may include grafts and bioprosthetic materials that you may not separately report with the codes available. Consider whether CPT® includes a code that accurately represents the procedure, or whether an unlisted code is more appropriate.
For example, consider a patient who had multiple incisional hernias and a necrotizing soft tissue infection following a laparotomy, including a strangulated hernia that required extensive mesh for closure. The patient’s infection was so great that it resulted in loss of significant anterior abdominal fascia, subcutaneous tissue, and superficial fascia. One of the defects was 20 x 20 cm, which is just less than 8 inches per side—nearly the size of a typical dinner plate.
The closure required massive flap mobilization from both flanks, which were each 50 x 30 cm (20 x 12 in). The procedure also included reinforcing the repair’s muscle layer with porcine biologic mesh.
The surgeon placed an additional piece of biologic mesh, 20 x 16 cm, under one set of hernias, and another 20 x 25 cm sheet under another area. Essentially, the patient’s entire anterior abdominal wall required reconstruction with mesh.
Coding for closure can be challenging, but if you follow the CPT® basics, they should guide you to the right decision. As a quick review:

• Know your terms: Keep in mind that “secondary closure” does not necessarily mean a second closure, and the term is often used to mean delayed secondary closure.
• Approach matters: A code may seem to describe the closure performed but, if the approach is not correct, the code does not apply.
• Be aware of bundles: You should not bill separately for included procedures, but also do not leave separate procedures unbilled. If you are unsure of bundling issues, check with the payer or seek out additional information regarding the coding you selected.

Terri Brame is the director of reimbursement and compliance for Coopersmith Health Law Group in Seattle, Wash. You may contact Terri at terri@coopersmithlaw.com.

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