General Surgery Coding Alert

Report repair alone or with lesion excision only.

In case you've ever wondered if you could separately report your surgeon's closure services for pretty much any surgical procedure, Correct Coding Initiative (CCI) edits version 18.3 answers a resounding, "no."

Effective October 1, 2012, CCI adds 233,242 new edit pairs, and most of those restrict reporting simple, intermediate, and complex repair codes (12000-13153) with practically every code from the start of the integumentary section (10040, Acne surgery [e.g., marsupialization, opening or removal of multiple milia, comedones, cysts, pustules]) to the end of the auditory system (69970, Removal of tumor, temporal bone) and beyond to include some radiology and medicine procedures.

"This release will go down in history as the Ripley's Believe it or Not quarterly change. In addition to the overwhelming volume of reasons that payers use to deny payment to a practice, you can add 1 million more, which is just about the size of the new [CCI] database," said Frank D. Cohen, MPA, MBB, senior analyst with The Frank Cohen Group, LLC, in his analysis of the changes.

Align With Surgical Practice Standards

The culprit in all these hundreds of thousands of edit pairs are the following codes:

• 12001-12018 -- Simple repair of superficial wounds ...
• 12020-12021 -- Treatment of superficial wound dehiscence ...
• 12031-12057 -- Repair, intermediate, wounds ...
• 13100-13153 -- Repair, complex ...

"Regardless of the massive number of edits involving these codes, it shouldn't really change the way you code," says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, audit manager for CHAN Healthcare in Vancouver, Wash.

"Surgical practice standards have always included the wound closure as part of a surgical procedure such as skin grafting, hernia repair, hemorrhoidectomy, etc.," Bucknam says. "These edit pairs just enforce the standards."

Focus on the Lesion Excision Exception

If your surgeon performs either a benign or malignant lesion excision, the fee includes only a simple closure. According to CPT® instruction for the following codes "Repair by intermediate or complex closure should be reported separately," using the following codes:

• 11400-11446 -- Excision, benign lesion including margins, except skin tag ...
• 11601-11646 -- Excision, malignant lesion including margins ...

That's why codes in the range 11400-11646 are just about the only surgical procedures that CCI 18.3 doesn't add to the list of 12001-13153 bundles.

For example: Your surgeon removes a 3.5 cm malignant lesion (including margins) from the patient's mid-back. The surgeon closes the wound in layers after extensive irrigation and undermining of tissues. When filing the claim, you should report 11604 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cm) for lesion excision and 13101 (Repair, complex, trunk; 2.6 cm to 7.5 cm) for the complex repair.

Take Advantage of Modifier Indicator '1'

What if your surgeon performs a wound closure at one site and a separate surgical procedure at a different site -- will these edit pairs keep you from capturing the pay you deserve?

No: The hundreds of thousands of CCI repair-code bundles are all marked with modifier indicator "1," which may allow you to report both the closure code and the bundled surgical procedure code. In certain clinical circumstances you can override --  not ignore -- CCI edits and receive separate payment for bundled codes. To find out if you can separately bill services, first check the "modifier indicator" in column F of the CCI spreadsheet (available online at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html).

How it works: "All edits consist of code pairs that are arranged in two columns (Column 1 and Column 2),"explains Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver. "Codes that are listed in Column 2 are not payable if performed on the same day on the same patient by the same provider as the code listed in Column 1, unless the edits permit the use of a modifier associated with CCI."

A "0" indicator means that you cannot unbundle the two codes under any circumstances. An indicator of "1," however, means that you may use a modifier to override the edit if the clinical circumstances warrant separate payment.

Tip: Before you override the edit, be sure you aren't falling into the misuse trap:

• Ensure that the closure code is for a procedure that takes place at a different body site or different operative session than the other surgical procedure.
• Append modifier 59 (Distinct procedural service) to the closure (column 2) code when overriding the edit is appropriate.
• Remember that you will need to have documented medical necessity for both the wound closure and a separate surgical procedure.