Wiki Guidance on the purpose of 13160

[jdibble]

Good Afternoon!

I have a surgeon who brought a patient to the OR for surgery. He opened the sutures that were placed by another doctor, proceeded to explore the wound wrist caused by penetrating glass. He repaired 5 tendons and then closed the wound. He wants to code 25270 x 5, 20103, 13160 and 11043. I advised him that 11043 and 13160 bundle with 20103 according to NCCI. I also tried to explain that 13160 would not be the correct code to use in this scenario since the opening of the wound and closure are inherent to the tendon repairs. He replied: "For code 13160, the wound he had been previously roughly approximated by another surgeon. As part of my surgery, I had to remove the sutures, open up the prior wound bed, and perform additional undermining of the soft tissue flaps in order to gain surgical exposure and for definitive wound closure. As the initially closure performed was not conducive to adequate wound healing, I believe 13160 applies." I again tried to explain that this portion would be included in the other CPT codes. (I also re-read his note, and he does not document anything about undermining of soft tissue flaps!).

I then provided him with documentation to support the descriptions of 20103 and 13160 not being a correct code if the surgeon opened the wound to perform the tendon repair as again that is included in the tendon repair as well as the wound exploration. He then answered: "If opening and closure are inherent to tendon repairs, does that mean if there is an open wound with associated tendon injuries, and surgery is done to repair the tendons, one cannot not bill for wound closure as part of the operative procedure?"

So - my question is first, am I wrong in understanding what the purpose of 13160 is - for a surgical wound that has dehisced or a secondary closure for one left open for infection? Or can this be used whenever a wound is reopened and closed with other surgeries (despite the NCCI edits!)?

Second question - How would you answer his question about an open wound so that he will understand? I believe the answer would be that the wound closure for the same surgical site would still be included in the tendon repair. Am I wrong?

Thank you all for your help. If I can get the answers to these questions, it would be so helpful as he is not the only doctor in this practice who believe they are entitled to bill for all inherent procedures!

Thanks,
Jodi

 

[NRaizman]

Any work required to open or reopen a wound to gain exposure and close on the way out is an integral part of the case and not separately reportable, with the exception being an intermediate or complex closure when appropriately documented. This is clearly stated in the NCCI Policy Manual and laid out in the GSD. If the surgeon did not adequately document the elements consistent with a higher level of closure (eg, undermining, retention sutures, layered closure, extensive skin edge debridement etc) then you cannot code the closure separately. The Secondary Closure code is generally only used when a surgeon closes someone else's wound that has dehisced or which was left open as a separate procedure. The NCCI edits get at this, but the code is an old Harvard code and has never been reviewed by the RUC, so there is no vignette.

20103 is only appropriate if you explore a wound and then don't do anything. If you explore and repair something, you can no longer code 20103.

I would respond that he could code the debridement code, the tendon repairs and, if the op note justifies it, intermediate or complex closure.

 

[jdibble]

Thank you again Dr. Raizman for your helpful response!