Questions from the Internet #3

Welcome to the third installment of "Questions from the Internet".

Remember that this question was posted on a forum and has been answered below. The question asked is written word for word and for privacy purposes all identifiers have been removed.

This article's question is:

"My Dr. for whom I'm billing for put me down to bill for laceration repair. Can someone provide me with the CPT code for it ??"

The question above is exactly as it was asked, word-for- word. There are many problems with this question and it has no simple answer and I will show you why.

First, we don't have access to the medical record to know if the medical care was provided. As always, if it wasn't provided we do not want to provide an answer that could involve us with an incident of fraud, waste or abuse! It's important to think about who asked this question. It may have been asked by someone who is a student in a medical coding class, so they go to a forum to get someone to provide them with the answer. In addition to not becoming involved with fraud, waste or abuse, we also don't want to involve ourselves with academic fraud. Academic fraud is when a student provides someone else's answer as their own. I look at it this way, if the student can't answer the question in class, how will they be able to do the work that the doctor expects them to do?

In the movie Air Force One, there was a saying, "If you give a mouse a cookie, they want a glass of milk." So, if you provide an answer, it's quite possible that they will be back for more answers and we expect medical billers and medical coders to be independent. When you don't provide these people the answer, they sometimes come back and use other methods to get their answer. One such method is a guilt trip is "I thought you would help a colleague who needed help."

Now apart from the potential fraud issues it is important to note that the person who asked the question will have no clue in determining if the answer supplied by "Joe Bloe" is correct. This can be dangerous because someone could say, use 99215 with modifier 25 and code 17280 (Destruction of skin lesions). This could cause the claim to be denied and open the doctor to medical record requests and audits. If the insurance company suspects fraud, they could go back 20 years with their audit of all of the doctor's claims and this could spell financial disaster for the doctor not just in claims denials but with refund demands!

Another problem with the question is that there are so many laceration repair codes which (without further information) makes it difficult to select the correct one. Laceration repairs are located in the Surgery section of the CPT manual, under integumentary system in the repair section. From the question we don't know what type of laceration repair that was performed. There are three (3) types listed in the guidelines: Simple, Intermediate, and Complex. For code selection we need further information such as where the laceration repair took place and the size of the repair (anatomical area is very important as a repair of the head is different than a repair of the face). Also what was used to repair the wound is also important: were sutures used or were adhesive strips applied?

Let's look at the three types of repairs first. The following is word for word from the American Medical Association's CPT manual:
Simple repair is used when the wound is superficial; e.g. involving primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures, and requires simple one layer closure. This includes local anesthesia and chemical or electrocauterization of wounds not closed.
Intermediate repair includes the repair of wounds that, in addition to the above, require layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure. Single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair.
Complex repair includes the repair of wounds requiring more than layered closure, viz., scar revision, debridement, (e.g. traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. Necessary preparation includes creation of a defect for repairs (e.g. excision of a scar requiring a complex repair) or the debridement of complicated lacerations or avulsions.
The coding guidelines provide additional information that is needed to select the correct code. Some of these are as follows:

The repaired wound(s) should be measured and recorded in centimeters (cms), whether curved, angular or stellate. When multiple wounds are repaired, add together the lengths of those in the same classification (see above) and from all anatomic sites that are grouped together into the same code descriptor. For example, add together the lengths of intermediate repairs to the trunk and extremities. Do not add lengths of repairs from different groupings of anatomic sites (e.g. face and extremities). Also, do not add together lengths of different classifications (e.g. intermediate and complex repairs). When more than one classification of wounds is repaired, list the more complicated as the primary procedure and the less complicated as the secondary procedure, using modifier 51.

Another question that is usually asked when this question is asked is: "Can I bill a 99205 office visit with this?" These usually fall under the impressive category of "Dunno". "Dunno" questions will probably not receive an accurate answer. We don't know if the repair was the main reason for the visit and we don't know if the medical record documentation supports a 99205 level visit. Modifier 25, Significant and separate evaluation and management is NOT a skeleton key to get the claim paid, nor is adding modifier 59, distinct procedure, to the wound repair code.

I have a long standing policy that I never code or bill if something is not documented. I never, ever guess! This policy has protected the doctors I work for and it has protected me.

The Internet has a wealth of information and that information should be used wisely. Wound repairs are not hard to code and bill and I have yet to meet an insurance company that doesn't cover wound repairs. Lastly, a wound diagnosis may open an insurance company investigation to determine liability to pay for the medical care. A simple common sense philosophy could be to send a copy of the medical record with the paper claim. This could help prevent claim delays and reduced revenue through delayed audits and investigations.

Never give up! Never surrender!

Steven M. Verno, CMBS, CEMCS, CMSCS, is a Professor of Medical Coding and Billing Instruction at Florida Metropolitan University.