General Surgery Coding Alert

Dig deeper to find the key to 'simple,' 'intermediate,' and 'complex' closures.

Getting the wrong repair code could cost your practice plenty -- for instance, you'd lose $214 for a 2.5 cm complex trunk closure wrongly billed as a simple trunk repair. And considering that some procedures include simple closure but allow you to separately bill for complex closure, you stand to lose even more if you don't distinguish repair complexity.

Read on for our experts' advice on how to assess the three closure levels and assign the best codes to earn your practice the pay you deserve -- every time.

Follow the Layers, Not the Depth, for Simple Repair

A simple repair involves primarily the dermis and epidermis. It might involve subcutaneous tissues, but not deep layers.

Draw the line: How do you know when a closure might involve subcutaneous layers but is still considered a simple repair? The difference is whether the surgeon closes the wound in multiple layers or just one. If the surgeon doesn't close the subcutaneous layer first, followed by a separate dermis/ epidermis closure, you have a simple repair.

Don't forget: Simple repair also includes "local anesthesia, and chemical or electrocauterization of wounds not closed," says Dilsia Santiago, CCS, CCS-P, a coder in Reading, PA.

Choose your code from 12001-12007 (Simple repair of superficial wounds of scalp, neck, axillae, eternal genitalia, trunk and/or extremities [including hands and feet] ...) or 12011-12018 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes ...), based on the wound's location and size.

Measuring tip: For excision of soft tissue tumors, measure the longest dimension of an oblong mass, according to John P. Heiner, MD, professor at University of Wisconsin Hospital and Clinics in Madison.

Go Deeper With Intermediate Repair

When you see the term "intermediate repair," it means your surgeon performed one of two things:

• Layered closure of one or more deeper layers (subcutaneous and superficial fascia/non-muscle) in addition to skin; or
• Single-layer closure of heavily contaminated wounds requiring extensive cleaning.

Find your intermediate repair codes at 12031-12037 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet ...); 12041-12047 (Repair, intermediate, wounds of neck, hands, feet and/or external genitalia ...); and 12051-12057 (Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes ...).

Cleaning must be above and beyond: Every closure requires some cleaning that won't necessarily justify an intermediate code. If you classify a procedure as intermediate because of the contamination level and cleaning, be sure you have the documentation to back it up. Payers will want notes regarding how extensive the wound was, the level of work involved in cleaning, and the amount of time spent on the procedure.

Look for any verbiage that will help describe the extra work involved. The use of words like "extensive," "heavily contaminated," "large," or "copious amounts" of particulate matter or debris will all help the payer understand that the cleaning is above and beyond that of a normal wound preparation.

Sort Through Complex Repair Choices

Complex repair involves layered closure, but you should consider more than layers to justify using these codes. Your surgeon's documentation should include notes about correcting a defect, performing extensive tissue debridement, or even creating a defect in order to repair a problem. For example, the repair may require a lot of preparation with undermining, retention, and debridement of large skin areas.

Choose your complex repair code based on body site, as follows:

• 13100-13102 -- Repair, complex, trunk ...
• 13120-13122 -- Repair, complex, scalp, arms and/or legs ...
• 13131-13133 -- Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet ...
• 13150-13153 -- Repair, complex, eyelids, nose, ears and/ or lips ...
• 13160 -- Secondary closure of surgical wound or dehiscence, extensive or complicated.

Opportunity: If your surgeon performs a lesion excision, the fee includes a simple closure. But that's not true for intermediate or complex closures -- you can list those services in addition to the excision code.

For example: Your surgeon removes a 2.5 cm benign lesion (including margins) from the patient's mid-back. He closes the wound in layers after extensive irrigation and undermining of tissues. When filing the claim, you should report 11403 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 2.1 to 3.0 cm) for lesion excision and 13100 (Repair, complex, trunk; 1.1 cm to 2.5 cm) for complex repair.