Last month, AAOS Now reported on the changes made to the Integumentary System section of CPT 2011 in the reporting of wound care services. This month’s column reviews changes in the same section regarding skin repair (closure) and replacement.
Specific guideline clarifications and changes were made to the complex repair and débridement services. These clarifications and changes relate to the code changes covered in last month’s article (wound débridement not associated with open fracture or dislocation and excisional débridement with open fracture), as well as to other code changes in the skin substitute/skin replacement section.
For skin replacement surgery and skin substitutes, guideline changes were made for surgical preparation codes (CPT codes 15002–15005). Codes are reported based on anatomic locations; the specific code definitions can be found in CPT 2011. Services are reported based on size, (ie, first 100 sq cm), with an associated add-on code for each associated additional 100 sq cm based on the CPT defined anatomic location.
Guideline changes were also made covering the application of skin replacements and skin substitutes (CPT codes 15100–15431). This range of codes defines the application of autografts, allografts, xenografts, and dermal replacements to a surface area that is void of skin. These codes may not be used to report the placement of a biologic mesh used as reinforcement material within a wound.
An orthopaedic CPT code for the placement of allografts does not exist—with the exception of spine and specific codes that say “with allograft.” The CPT codes that state “with allograft” include the work associated with the placement/insertion of the allograft, so no code is separately reportable for obtaining or “harvesting” the allograft. CPT codes 20930 and 20931 are reported as appropriate in spine surgery coding only. Note that 20930 has 0 relative value units (RVUs), although 20931 has 1.81 work RVUs, reflecting the surgeon’s effort in fashioning the structural allograft.
For example, a patient has a contaminated laceration on the foot. When the patient was first seen, the orthopaedic surgeon débrided the laceration. Several days later, the patient was taken to the operating room and the surgeon performed a surface area débridement to prepare the wound for a complex closure. The patient was not in a global period.
The surgeon documented surgical preparation of a 5 cm × 2 cm open wound on the right thigh, with a complex closure measuring 30 sq cm. Fig.1 shows the appropriate coding for this procedure, using the following codes:
- 13121—Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm
- 13122—Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure)
- 15004-51—Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1 percent of body area of infants and children
Fig. 2 shows an alternative coding format that reports units for the add-on code, 13122. This format should be used only if the payer requires it. When all units are reported on one line, the fees should reflect the number of units. In this case, because the single line for code 13122 reflects 3 units, the fees are tripled.
Some payers may require the use of the modifier 59 on the second through fifth add-on code, while others may require that the add-on code is reported in units. Know how your payers want you to report this situation to avoid delays in payment.
Active wound care management
CPT codes 97597 and 97598 were revised to include “débridement, open wound (eg, fibrin, devitalized epidermis and/or dermis)” to support the deletion of CPT codes 11040 and 11041. CPT code 97597 defines débridement based on surface area and applies to the first 20 sq cm; CPT code 97598 is an add-on code used to report each additional 20 sq cm. Based on guideline changes, however, CPT codes 97597 and 97598 may not be used when wound débridement is reported with CPT codes 11042–11047.
If a patient has multiple wounds, one of which requires skin débridement alone while others require more extensive débridement, modifier 59 should be used to indicate a different anatomic location. For example, a foot and ankle surgeon performs débridement to muscle of a 6 sq cm open wound on the lateral posterior calf and a selective débridement of skin in a 3 sq cm wound on the medial posterior calf. The appropriate coding for this procedure is shown in Fig. 3, using the following codes:
- 11043—Débridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less
- 97597—Débridement (eg, high pressure waterjet with/without suction, sharp selective débridement with scissors, scalpel and forceps), open wound, (eg, 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
- The use of modifier 59 in this scenario indicates the selective débridement of a separate wound.
- Action steps
- Review the coding rules pertaining to each of the revised sections related to débridement services, repair services, and the skin substitute codes.
- Ensure documentation supports the requirements for each code or service as described (depth, size, and location when appropriate).
- Append modifiers as appropriate depending on other services reported at same session.
- Appeal to payers who deny payment for CPT codes 11010–11012 that are reported more than one time per operative session.
- Audit operative notes to ensure that the documentation supports the services reported.
Mary LeGrand, RN, MA, CCS-P, CPC, is a consultant with KarenZupko & Associates, Inc., and focuses on coding and reimbursement issues in orthopaedic practices. This article has been reviewed by members of the AAOS Coding, Coverage, and Reimbursement Committee.