We recently starting seeing Aetna deny complex repair CPT Codes 13101 etc. They will pay the excision and then deny the repair. We submit medical records, and its still rejecting or they are taking over 90 days to respond. We even include the pathology report, site photos that clearly show the the size documented was valid. For example we billed 11402 and 13101. Any guidance is greatly appreciated.
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Wiki Aetna - Complex Repairs w Exc of Benign lesion - Any Complex Repair
- Thread starter dawn@midtown-derm.com
- Start date
trish69
New
Our office is also experiencing the same issue. Aetna is denying the complex repair with the excisions. Is there a change in the documentation Aetna wants for complex repairs? What has recently changed, if anything? Any help is appreciated.
jason.lang
Contributor
This has been a burr in my backside as well not only for Aetna but UHC. I'm still searching for specific documentation requirements and so far CMS, NGS J6-our mac, Aetna nor UHC have specific policies for documentation of "complex repair". There was another thread going that I'm following regarding this very issue saying it started back in May 2023. I've signed up for a non-member account at aad.org however, unless a member you cannot access anything. I would have a AAG.ORG provider member inquire with the specialty society about documentation requirements.
This was the Procedural note UHC reviewed:
Patient comes in today regarding a 1-1/2 cm nodular lesion with ulcerative center on the left dorsal wrist. It is on baby aspirin.
The patient is prescribed anticoagulants long term. Pros and cons regarding continuing, slowing down, and/or stopping them for the procedure was discussed which include but are not limited to excess bleeding, hematoma, blood clots, embolism strokes, cardiac events. The patient understood and verbalized understanding.
Patient skin reveals he does have some actinic keratoses as well.
For all the above problems unless otherwise indicated the findings and treatment options were discussed. The patient wishes to observe them which I think is appropriate. We discussed signs and symptoms which would require reevaluation. They will contact us if this occurs. They verbalized understanding of all this.
[Left dorsal wrist]
Recommendations: I discussed with the patient pros and cons of observation versus excision. I think we should consider excision of the area to rule out malignacies. They verbilized understanding, agreed and wanted to proceed.
Informed consent was discussed and obtained. An explanation of the procedure was provided. The potential risks of the procedure were discussed with the patient that include, but are not limited to: bleeding, infection, unacceptable or hypertrophic scarring, poor cosmetic results, contour irregularities, fluid collection, chronic pain, numbness, changes in sensation, wound healing problems, recurrence, incomplete excision, no improvement of underlying symptoms or problems, distortion of surrounding normal anatomic features, need for re-excision depending on pathology, damage to underlying vital structures such as nerves, blood vessels, muscles, and the glands, and reactions to local anesthetic medications and dressings. The benefits of the procedure, the risks and benefits of alternative procedures, as well as the possible consequences of not undergoing the procedure, were discussed. The patient verbalized understanding and gives consent to proceed.
The left dorsal wrist area was sterilely prepped and draped and locally infiltrated with 1% lidocaine mixed with epinephrine. The lesion/mass was 1.5 cm in size and a minimum of at least 2-5 mm margin was excised around it with the total excision margin being 2.1 cm. The wound was extensively undermined more than the width of the defect at the level of the underlying fascia and the skin and subcutaneous tissue was advanced to facilitate closure, decrease tension and to prevent distortion of the normal anatomic features. Dog ears were then excised. The wound was then closed in multiple layers, with the total closure length measuring 3.8 cm.
***********************************************************************************************************
Biopsy report results:
Final Diagnosis:
Skin, left wrist, excision:
-Squamous cell carcinoma, well-differentiated
-Margins of excision, negative for tumor
ICD-10: C44.629
Electronically verified by xxxxxxxxxx xxxxxxx, MD
Electronic Signature xx/xx/xxx xx:xx
Specimen Source:
Skin, Left wrist excision
Gross Description:
The specimen containers(s) and requisition have the same patient name.
Received in 10% neutral buffered formalin for formalin-fixed paraffin-=embedded sections labeled “L Wrist” is an unoriented 3.7 x 2.2cm fragment of tan skin excised to the depth of 0.2 cm. A 1.7 x 1.5 x 0.5 cm white firm dome -shaped lesion is present on the skin surface and is 0.5 cm from the closest margin. The specimen is inked, serially sectioned, and entirely submitted for histologic study as follows: A1 and A2 tips, A3 through A7 remainder.
Clinical information:
Skin biopsy, left wrist, lesion
UHC Optum performed the review of the documentation and this was their findings:
"The submitted medical records indicated that extensive undermining was performed more than width of the defect; however, the records does not indicate that undermining was along the entire length of one edge and there is no extensive undermining measurement documented within the description of the procedural note."
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sfbug23
Contributor
I too am getting a denial from BCBS ND, when I send in an appeal with chart notes, etc I get this from them in an appeal letter back from BCBS ND. 
Orthocoderpgu
True Blue
Is there a size conflict between 11402 and 13101? Code 11402 goes up to 2cm which includes margins. Code 13101 starts at 2.6cm. If the lesion was 2cm in size, why would it be paired with a closure code which is larger? I would look at that and make sure that all requirements for complex closure are documented.
jamiecourt
New
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I reached out to the senior auditor at United Healthcare for the documentation requirements for complex repairs and this is the response I received:
Complex Repair
Complex repair includes the repair of wounds that, in addition to the requirements for intermediate repair, require at least one of the following: a) exposure of bone, cartilage, tendon or named neurovascular structure; b) debridement of wound edges (e.g., traumatic lacerations or avulsions); c) extensive undermining (defined as a distance greater than or equal to the maximum width of the defect, measured perpendicular to the closure line along at least one entire edge of the defect); d) involvement of free margins of the helical rim, vermilion border, or nostril rim; or e) placement of retention sutures. Necessary preparation includes creation of a limited defect for repairs or the debridement of complicated lacerations or avulsions. Complex repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions, excisional preparation of a wound bed (15002-15005) or debridement of an open fracture or open dislocation.
Intermediate Repair
Intermediate repair includes the repair of wounds that requires layered closure of one or more of the deeper layers of subcutaneous tissue and in which superficial (non-muscle) fascia is required in addition to the skin (epidural and dermal) closure. Intermediate repair includes limited undermining, which is defined as a distance less than the maximum width of the defect, measured perpendicular to the closure line, along at least one entire edge of the defect. Intermediate repair may also be reported for single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter.
Complex Repair
Complex repair includes the repair of wounds that, in addition to the requirements for intermediate repair, require at least one of the following: a) exposure of bone, cartilage, tendon or named neurovascular structure; b) debridement of wound edges (e.g., traumatic lacerations or avulsions); c) extensive undermining (defined as a distance greater than or equal to the maximum width of the defect, measured perpendicular to the closure line along at least one entire edge of the defect); d) involvement of free margins of the helical rim, vermilion border, or nostril rim; or e) placement of retention sutures. Necessary preparation includes creation of a limited defect for repairs or the debridement of complicated lacerations or avulsions. Complex repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions, excisional preparation of a wound bed (15002-15005) or debridement of an open fracture or open dislocation.
Intermediate Repair
Intermediate repair includes the repair of wounds that requires layered closure of one or more of the deeper layers of subcutaneous tissue and in which superficial (non-muscle) fascia is required in addition to the skin (epidural and dermal) closure. Intermediate repair includes limited undermining, which is defined as a distance less than the maximum width of the defect, measured perpendicular to the closure line, along at least one entire edge of the defect. Intermediate repair may also be reported for single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter.
jason.lang
Contributor
Thank you very much for this information, it confirms what I thought but it's in writing (minus your name) to present to the provider.
Have a great day
