Know When to Report Excision or Repair (or Both)

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In Billing
November 28, 2012
5 Comments
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Excision or RepairYour surgeon has excised three skin lesions from the patient’s left shoulder, and now must close the wounds. Should you report both the excisions and repairs? If so, which is primary?

CPT® guidelines instruct that all benign (11400-11471) or malignant (11600-11646) skin lesion codes include simple wound closure, but you may separately report intermediate (12031-12057) and complex (13100-13153) repairs. Medicare and payers who follow National Correct Coding Initiative (NCCI) edits are more restrictive, and will bundle intermediate and complex repairs for excisions of benign lesions of 0.5 cm or less (11400, 11420 and 11440). You may separately report intermediate and complex repairs for malignant lesions of any size.

Here a quick decision tree to help you decide when it’s appropriate to report repair separately:

• Is it a simple repair (e.g., involving “primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures”)?

• If yes, do not report the repair separately.

• If no, was the lesion malignant?

• If yes, report the repair separately.

• If no, does your payer observe NCCI edits?

• If no, report the repair separately.

• If yes, was the lesion larger than 0.5 cm?

• If yes, report the repair separately.

• If no, do not report the repair separately.

When reporting both the excision and repair, list as primary that service having the highest relative value units.

When repair is performed using an adjacent tissue transfer, however, excisions at the same location (whether for benign or malignant lesion) are always included in the repair. CPT Assistant (July 2008) provides the following example:

A physician excises a 1.5 cm lesion on the cheek with an excised diameter of 1.8 cm (primary defect, approximately 3.2 sq. cm.) and performs an adjacent tissue transfer (flap dimension of 1.4 x 3.0 cm., which equals a 4.2 sq. cm. secondary defect). Based on the total area of the primary and secondary defects (7.4 sq. cm.) and the location (cheek), the correct code is 14040. The lesion excision is included in the tissue transfer and is not separately reported.

5 Responses to “Know When to Report Excision or Repair (or Both)”

  1. Robin Szuchman says:

    These types of emails are wonderful for preparing for the exam . I will pass this to my department as I have about 6 billers sitting for the exam this saturday 12-8-2012.

  2. Lisa Jackson, CPC says:

    It is also good to note that when multiple wounds are repaired same day, same classification (intermediate or complex) and from all anatomic sites that are grouped together into the same code descriptor, need to be added together to bill. i.e. Add together lengths of intermediate repairs to the trunk and extremities and the total of those lengths is the repair code you bill. This is written out completely in your CPT book under Surgery/Integumentary section, repair (closure). Repair codes start with 12001.

  3. Ruth says:

    Thank you so much for sharing this. I am having a difficult time with this. I think this will help me better understand.

  4. chandani says:

    This will help me a lot for the exam this Sunday 12-09-2012.

    Thanks

  5. sean says:

    Wow thanks for the insight..currentlyundergoingmedical billing classes and its a tricky Su bject..very informative

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