Part B Insider (Multispecialty) Coding Alert

Published on Sat Aug 26, 2006 PDF

If the patient needs tendon repair, you can't bill for wound care

Do you know the exceptions to the rules for intermediate or complex tissue repair? If not, you could be overbilling and inviting denials or overpayments down the road.

Coders often believe they can bill separately for tissue repair as long as the repair is intermediate or complex. This is true in many cases, note experts. For example, the CPT guidelines state, -Complex repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions.- But there are some important exceptions--cases in which you should never bill for tissue repair.

Exception #1: If a lesion is deeper than the skin, then you don't bill for repair no matter how complex it was, says Margie Vaught, coding consultant in Ellensburg, WA. If a lesion is in the submucosa, sub-muscle or subfascial layers, then you-ll be billing in the 23xxx series of codes. You don't bill separately for repair with those codes, says Vaught.

Exception #2: Many coders become confused about a situation where a patient comes in with a lacerated hand and then it turns out she's also cut her tendon, says Vaught. In that situation, coders often believe they can bill separately for the tendon repair and the repair of the wound.

But CPT guidelines say you can't bill separately for the wound repair, because -your wound becomes your access.- Normally, the tendon repair code includes your approach to the tendon, but because the patient already has an open wound, the patient was -already wide open,- says Vaught.

The same goes for fracture repairs with open wounds--that is, you can't bill for that repair separately unless the physician has to perform a skin graft as well, says Vaught.

The December 2000 CPT Assistant says that wound closure codes 12000-13000 should be considered inclusive in tissue laceration and repair code 26418, Vaught notes.