Orthopedic Coding Alert

Service could be part of package, or be separately codeable.

Most orthopedic coding involves reporting the surgeries that your physician performs — knee fixes, shoulder surgeries, broken arms, etc. — but what about when your physician has to perform less frequent services, such as wound repair?

It might not be the orthopedist’s bread and butter, but you will be called upon to consider whether or not to code wound repairs on some claims; when that happens, you’ve got to be ready to code.

Keep this quick primer handy in case you need a bit of guidance on whether or not to code the next wound repair service you see.

Repairs Typically Occur in Context of Other Surgeries

Since yours isn’t a dermatology or primary care practice, patients will rarely come to an orthopedist for wound repair only — though it is not unheard of. Most times, the repair is part of a larger surgical package, confirms Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

When orthopedists perform wound repair, Bucknam says “there would usually be a fracture — typically an open fracture — or some other open wound with damage to an underlying musculoskeletal structure: bone, tendon, ligament, cartilage, etc.

“These will be fractures, avulsions, detachments, ruptures, tears, etc. This will typically be due to traumatic injuries,” explains Bucknam.

1-2 Layer Repair Often Bundled

When your orthopedist performs a simple repair, you’d choose a code from the 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less) to 12017 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm), depending on encounter specifics.

“Simple closure is closure of only the skin in a single layer using sutures, staples, or even adhesive skin glue,” reports Bucknam. “It is typically only separately billable if it is the only procedure being performed. It would bundle into virtually any musculoskeletal procedure performed at the same site.”

The same bundling would likely affect most of the codes in the intermediate repair set: 12031 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less) through 12057 (Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm). Unless, however, it is the only service the physician provides.

“An intermediate closure is a layered closure. The provider should either document reapproximation of the subcutaneous tissues followed by separate closure of the skin or specify that the wound was closed in layers,” explains Bucknam. “Again, intermediate closure is often bundled into ortho procedures at the same site because MS structures are, by definition, below the subcutaneous tissue and you can’t bill separately for closure of operative procedures.”

Best bet: For simple and intermediate repairs that stand alone, use the above guidance to choose between the two types of fixes. Remember, these repairs are most likely bundled into surgical codes that the orthopedist might use; you can, however, report these repairs along with a significant, separately identifiable evaluation and management (E/M) service, such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity … ).

When reporting an E/M with a simple or intermediate repair, append modifier 25 ((Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code to show that the services were separate. Don’t bother with modifier 57 (Decision for surgery), as codes 12001 through 12057 all have global periods of 10 days.

Code Complex Repairs Separately? Maybe

When considering complex repair codes 13100 (Repair, complex, trunk; 1.1 cm to 2.5 cm) through +13153 (Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less (List separately in addition to code for primary procedure)), things are more interesting — and trickier.

Why? Complex repair starts with layered closure and then gets more involved, Bucknam says. So, in certain situations, you might be able to report a complex repair code in addition to any other portions of the surgical package.

“The most common complex closure is a layered closure where there is undermining — loosening the skin from the subcutaneous tissue in order to pull the skin to close a larger defect,” explains Bucknam. “However, complex closure can also be billed when the surgeon creates the defect: for example, a scar revision.”

When you report a complex repair, “there must be documentation of the layered closure as well as good and believable documentation of the extra work required for the complex closure,” Bucknam warns.   

Do This on Multiple Repairs

When you are reporting multiple repairs for the same patient during the same encounter, remember these tips:

• Add would lengths together when they are of the same severity and in the same anatomical area. “And remember that if there is a stellate wound, each separate arm of the wound should be measured separately and added together,” Bucknam says.  
• Code the wounds separately when they differ in severity or in anatomical area. According to Bucknam, “you can’t add together wounds that require different complexities of repairs or different anatomic areas. The reimbursement for more delicate repairs is higher than for repairs in areas like the back or legs, where neither function or scarring is a very significant factor.”