13160 Late Closure of Wounds in Office Setting

[bharmon518]

I have a claim where 13160 was billed with a 58 modifier after surgery. Provider did a late closure of the wound in the office setting. Aetna denied stating "following CMS guidelines" it cannot be billed in the professional setting, but I see nothing in Codify/CMS/otherwise that states it can't be billed in the professional or outpatient setting. I see commercial payers, including Aetna, as well as Medicare also paying for a complex wound repair in the office setting as well, which I see little difference as they contain similar elements in the procedure. Has anyone come across this issue or successfully appealed/done a second level appeal? Thanks!

 

[amyjph]

If you search the CMS fee schedule that code has NA in the non-facility column. I am guessing Aetna will not pay for it in the office setting. Are you sure this is the correct code for what was done in the office? I have never (in over 20 years) seen/coded 13160 done in office. They always take them back to an ASC or hospital. Usually, this is because of a dehiscence/breakdown of the surgical wound and it requires debridement and it has to be extensive/complicated. Many times infection is involved. Did they leave the original surgical wound open on purpose for later closure (delayed primary) or did the closed wound breakdown? Complex repair (13100-13153) is not the same thing as secondary closure of a surgical wound/extensive or complicated. I would make sure the coding choice was correct. Could it be 12020 or 12021? What is the provider type/surgery that was done initially?

NA in that column means it is rarely or never done in an office/non-facility setting.

https://www.cms.gov/medicare/physician-fee-schedule/search?Y=0&T=4&HT=0&CT=3&H1=13160&M=5