General Surgery Coding Alert

Question: Based on the CPT description and notes, it appears that the new soft tissue tumor excision codes don't include complex closure. Our computer billing program, however, will not let us report any complex closure codes with any soft tissue tumor excision codes. Should we be billing the complex closure in addition to the tumor excision codes using modifier 59?

Pennsylvania Subscriber

Answer: Although CPT states that you can bill for complex closure (13100-13160) in addition to the soft tissue tumor codes added in 2010, Medicare has stated that the excision/resection codes include simple, intermediate, and complex repairs. That means you'll need to bill these cases based on individual payer rules. CPT 2010 includes 72 new/revised 20000 level codes for soft tissue tumor excisions and resections that describe location, size, depth, and malignancy -- for instance, 21935 (Radical resection of tumor [e.g., malignant neoplasm], soft tissue of back or flank; less than 5 cm.).

CPT 2010 instructions in the musculoskeletal system introduction state that closing the defect for some excisions "may require a complex repair, which should be reported separately."

Problem: If you have a billing system that follows Medicare rules, it will not allow you to bill separately for a complex closure at the same site. But you should not report modifier 59 (Distinct procedural service) to any payers.

Payer dictates solution: For Medicare, using modifier 59 indicates that the service is for a different site -- which it is not, in this scenario. Don't bill the complex closure for a soft tissue tumor excision to Medicare.

For a non-Medicare payer that allows billing according to the CPT rules, you can bill both the appropriate soft tissue and complex closure codes -- but you shouldn't append modifier 59 because no bundling issue exists.

Caveat: You may need to add modifier 59 to work around your internal system so that it will allow you to bill a soft tissue tumor and complex closure together. Make sure you're following payer rules before you consider this solution.