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.

Coding an Omental Flap

Question:

Can add-on code 49905 (omental flap) be  reported for buttressing an incision or anastomosis?  For example after a colectomy?  Or is the intent of the code, reconstruction of a defect only.

49905 Omental flap, intra-abdominal (List separately in addition to code for primary procedure)

Answer:

No, buttressing a formed anastomosis (made by staples or sutures) with extra suture, mesenteric fat, or even fibrin sealant is all considered inherent to the creation of that anastomosis and would not be separately reported.

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

Simple Laceration Repair on Skin Right Upper Eyelid

Question:

My physician did a simple laceration repair on the skin right upper eyelid.  What procedure code should I report?  My physician wants to use 67930.

Answer:

For a simple repair of the skin of the eyelid, you should report 12011-12018 based on cm size of the repair.  Report 12011 for a total length of 2.5 cm or less; 12013 for 2.6 cm to 5 cm; 12014 for 5.1 cm to 7.5 cm; 12015 for 7.6 cm to 12.5 cm; 12016 for 12.6 cm to 20 cm; 12017 for 20.1 cm to 30 cm; and 12018 if the total length is greater than 30 cm.  When reporting repair of wounds, the lengths of all repairs are added together and the total is listed for each anatomical site. If the repair involves the lid margin you should report the repair with CPT 67930 (Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva direct closure; partial thickness) or 67935 (full thickness).

*This response is based on the best information available as of 11/02/17.

Why am I Receiving a Denial When I Report a Joint Injection and a Trigger Point Injection on the Same Date of Service?

Question:

Our orthopaedic surgeon performed and clearly documented a joint injection to the right shoulder and a trigger point injection bilaterally to the trapezius muscle. We are receiving denials when we report CPT code 20610 and 20552 on the same claim form? Are you able to assist us in understanding if we have coded correctly or how to appeal?

Answer:

You are correct to question this denial!  There is no clinical reason for this denial assuming your documentation and medical necessity supports reporting CPT 20610 and 20552 as defined in your scenario.  If the payor is Medicare, or a payor who follows NCCI rules, the answer has to do with NCCI edits between the code combinations.    Several years ago, Medicare identified coding patterns where the 2055x series of codes were reported during the same session as joint or other musculoskeletal surgical injections.  In doing their due diligence, Medicare found in record review that the 2055x series was being incorrectly reported for the administration of a local anesthetic prior to the definitive injection.   In the KZA orthopaedic coding workshops the surgical package and administration of local anesthesia is discussed as the rationale for the creation of this edit.

This is an example where the use of modifier 59 (distinct procedure modifier) has a role in claims reporting!

Report:

20610 linked to the shoulder diagnosis

20552-59linked to the appropriate diagnosis to support the trigger point injection

We are confident the denial, while not identified in your Question:, was for a bundled or service integral to another procedure on the same day. It is not uncommon for the Center for Medicare and Medicaid Services (CMS) to implement edits when a pattern of incorrect code combinations are identified.

The following statement is found in the January 2017 NCCI Guidelines (CHAPTER IV SURGERY MUSCULOSKELETAL SYSTEM):

Injections of local anesthesia for musculoskeletal procedures (surgical or manipulative) are not separately reportable. For example, CPT codes 20526-20553 (therapeutic injection of carpal tunnel, tendon sheath, ligament, muscle trigger points) should not be reported for the administration of local anesthesia to perform another procedure. The NCCI contains many edits based on this principle. If a procedure and a separate and distinct injection service unrelated to anesthesia for the former procedure are reported, the injection service may be reported with an NCCI-associated modifier if appropriate.

*This response is based on the best information available as of 11/02/17.

EMG Guidance with Extremity Chemodenervation

Question:

How many times can code 95874, Needle electromyography for guidance in conjunction with chemodenervation, be reported If chemodenervation is performed on four extremities (e.g., 64642, 64643, 64644, 64645)?

Answer:

Per CPT, code 95874 is reported for each corresponding chemodenervation of the extremity.  In the example, four chemodenervation codes were reported, therefore, the needle electromyographic (EMG) add-on code 95874 would be reported four times for the scenario described in the Question:.

Source:CPT Assistant October 2014

*This response is based on the best information available as of 10/05/17.

Coding Debridement for an Ulcer

Question:

I debrided and ulcer. How do I know if I use 97965 or 11042?

Answer:

Code 97597 is described by CPT as adebridement(e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less.By definition it is exclusively for selective debridement of the skin, epidermis and dermis.

In contrast, code 11042, is for a deeper selective debridement, one that includes the dermis, epidermis and subcutaneous tissue. The code description statesDebridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less.

For any debridement make sure to document the depth of the tissue debrided, the location of the debridement and the size of the debridement. Other selective debridement codes (11043 and 11044) are also coded by the depth of tissue removed; muscle and/or fascia for 11043 and bone for 11044.

*This response is based on the best information available as of 09/21/17.