Complex Closure with a Soft Tissue Tumor Code

Question:

Can I also bill for the complex repair when I’ve also excised a soft tissue tumor like a lipoma in the 21552-21555 series of codes?

Answer:

Actually CPT says these soft tissue tumor codes include the simple or intermediate repair and a complex repair may be separately reported.  That said, Medicare and many other payors will not reimburse the code because they consider it to be a primary closure.

*This response is based on the best information available as of 11/30/17.

Debridement Prior to Skin Grafting

Question:

I’m taking a patient to the OR for debridement of a dehiscent surgical wound and will skin graft it for closure. I’m looking at getting 11042 (debridement) and the skin graft codes precertified. Is this right?

Answer:

Not exactly.  You’re right about the skin graft code(s).  However, we do not recommend the 11042 – 11047 codes.  These codes are used for wound debridement but only when you are debriding an open wound with no intention of closing it; you expect the wound to heal by secondary intention.  In your example, you will be closing the wound.  Therefore, the more accurate code is a surgical preparation code (15002 – 15005) forexcision(note the term is not debridement) of the open wound to prepare a viable wound surface for grafting.

*This response is based on the best information available as of 11/16/17.

Billing for Pre-Op H&P Visit

Question:

Hospitals require that we do an H&P within 30 days of taking a patient to the OR. If this visit is more than 48 hours prior to surgery, is that a billable visit?

Answer:

No, the H&P in this case is not a billable visit.  This question comes up often and was addressed by AMA CPT Assistant in the following excerpt:

“If the decision for surgery occurs the day of or before the major procedure and includes the preoperative evaluation and management (E/M) services, then this visit is separately reportable. Modifier 57, Decision for Surgery, is appended to the E/M code to indicate this is the decision-making service, not the history and physical (H&P) alone. If the surgeon sees the patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days or 2 weeks) the visit is not separately billable as it is included in the surgical package. Example: The surgeon sees the patient on March 1 and makes a decision for surgery. Surgery is scheduled for April 1. The patient returns to the office on March 27 for the H&P, consent signing, and to ask and clarify additional Question:s. The visit on March 27 is not billable, as it is the preoperative H&P visit and is included in the surgical package.”

Source: AMA CPT Assistant, May 2008/Volume 19, Issue 5, pp. 9, 11

CPT says once the decision is made to proceed with surgery the subsequent visits related to the procedure (e.g., doing H&P, getting consent form signed, answering Question:s) are included.  However, in some cases a patient may be a candidate for a surgical procedure but has a number of medical issues (such as cardiac disease and asthma) that require a medical evaluation to determine if he/she is healthy enough for surgery.  After the patient has had a “medical clearance” he/she returns to you to review the medical doctor’s evaluation and you at that point decide to proceed with surgery.  This visit can be billed as an E&M visit as the decision for surgery is just now being made.

*This response is based on the best information available as of 04/13/17.

Three Layer Closure = Complex Repair?

Question:

Is a 3-layer closure after a malignant skin lesion removal considered a complex repair code (131xx)?

Answer:

No. Actually, CPT says a “Complex repair includes the repair of wounds requiringmore than layered closure, viz., scar revision, debridement (e.g., traumatic lacerations or avulsions), extensive undermining, stents or retention sutures.” The emphasis (bold) is added to show that a complex repair code requires more than a layered closure. The intermediate repair (12xxx) code guidelines say a “layered closure of oneor moreof the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure” is performed. The emphasis (bold) is added to show that one or more (e.g., two, three) layers repaired is considered an intermediate repair after excision of a skin lesion.

*This response is based on the best information available as of 05/26/16.

Excision of “Dog Ear” at Time of Breast Reconstruction

Question:

What code should I use for excision of a “dog ear” of the reconstruction flap that was done at the same time as the second stage of breast reconstruction?

Answer:

Actually, excision of the dog ears is included in the primary procedure code for your second stage procedure and should not be separately reported with a lesion removal code (e.g. 114XX) or any other code.

*This response is based on the best information available as of 03/17/16.

Split Thickness Skin Graft

Question:

The doctor did a split-thickness autograft of the leg. I can’t find the CPT code for this procedure for an adult. I see only CPT codes for infants and children. Can you tell me where the codes for adults are?

Answer:

There are two stand-alone codes for split thickness skin grafts:

CPT Code	Descriptor
15100	Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children
15120	Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children

Note that the code descriptors say, “first 100 sq cm or less, or 1% of body area of infants and children.” That means the code applies to both adults and children. If an adult, you’ll use the area in square centimeters documented in the note. If an infant or child, you’ll use 1% of the body area as your guide for coding the area grafted.

*This response is based on the best information available as of 12/17/15.