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Question: A patient presented with a right forearm laceration. The surgeon extended the laceration to explore the wound. They found that the flexor tendon needed repair, which was completed, and then they performed a complex repair of the wound.

The surgeon submitted 20103, 25260, and 13121 to report the procedures. I informed them that the extension and closure cannot be reported separately per National Correct Coding Initiative (NCCI) guidelines. The surgeon simply replied that they’ve “always reported the closure.”

Who is correct in this situation, and what codes should we report?

Texas Subscriber

Answer: You are correct in this situation.

Code 20103 (Exploration of penetrating wound (separate procedure); extremity) is the exploration of the wound without any repair, and 13121 (Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm) is a complex repair of a wound on the arms. However, 13121 is a column 2 code to 20103, according to the NCCI procedure-to-procedure (PTP) edit pairs. This means that the repair is inherently included in the wound exploration procedure and cannot be unbundled unless it is appropriate.

Code 25260 (Repair, tendon or muscle, flexor, forearm and/or wrist; primary, single, each tendon or muscle) represents the flexor tendon repair following a traumatic injury. Once again, 13121 is a column 2 code to 25260, meaning that the closure is bundled into the tendon repair procedure. The Medicare Physician Fee Schedule lists 25260 with a 090 (90-day) global period, and according to Chapter 4 of the Medicare’s NCCI coding policy manual, “Wound repair CPT^® codes 12001-13153 shall not be reported separately to describe closure of surgical incisions for procedures with global surgery indicators of 000, 010, 090, or MMM.”

Furthermore, the wound exploration code cannot be reported with 25260 either. Chapter 1 of the NCCI coding policy manual states that surgical field exploration is vital to the operative procedure and isn’t separately reportable. The agency adds, “a procedure designated by the CPT^® code descriptor as a ‘separate procedure’ is not separately reportable if performed in a region anatomically related to the other procedure(s) through the same skin incision, orifice, or surgical approach.” Therefore, you’re unable to report 20103 with 25260.

In summary, you’ll report 25260 for the physician’s procedures.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC