Hot coding topics from the field

By Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, Manager, Lead Coding and Reimbursement Strategist, June 1, 2023

Academy coding staff address important coding topics each month in DermWorld Coding Consult. Read more Derm Coding Consult articles.

Payer denials for adjacent tissue transfer or rearrangement surgery are on the rise

It has come to the Academy’s attention that some private payers are denying reimbursement of claims reported with CPT^® codes 14000 - 14350 Adjacent tissue transfer or rearrangement indicating the medical record documentation does not support the service provided. Private payer auditors have denied flap claims due to a lack of wording indicating the “tissue was carried over” in the medical record documentation.

The genesis of the “tissue was carried over” flap documentation wording is found in Chapter III of the Integumentary System, Section H. Repair and Tissue Transfer of the National Correct Coding Initiative (NCCI) policy manual, which states in part that adjacent tissue transfer (ATT) or rearrangement includes the lesion excision (CPT codes 11400-11646) and intermediate or complex repair (CPT codes 12001-13160). Therefore, lesion excision (11400-11646) and repair (12001-13160) cannot be reported separately when performed on the same lesion that is repaired with an ATT (CPT codes 14000-14350). Debridement (CPT codes 11000-11001, 11004-11006, 11042-11047, 97597, 97598, 97602), necessary to perform a tissue transfer procedure when performed on the same lesions repaired with an ATT, is also included in the ATT procedure and not separately reportable.

The policy further states that extensive undermining of adjacent tissue to achieve closure of a wound or defect may constitute complex repair, not tissue transfer and rearrangement. Tissue transfer and rearrangement require that adjacent tissue be incised and carried over to close a wound or defect.

Payer documentation requirements

To avoid claim denial, the Academy encourages dermatologists to include a statement that indicates that the tissue was ‘carried over’ to close the defect. Thus, when there is a pre- or post-payment review of the medical record documentation, it will describe the procedure as it was performed as well as meet the payer documentation requirements.

Example:

“Due to geometric and functional constraints, a flap reconstruction was performed to reconstruct the defect. To that end, adjacent tissue was incised and carried over to close the defect in the following manner…”

In the meantime, the Academy is continuing to advocate and collaborate with the affected payers to update them that the wording requested for inclusion in the medical record documentation is part of the procedure description and not a strict documentation requirement for ATT or rearrangement.

Contact us with questions.

Coding update: Reporting suture removal

Then…

Spring 2013 DCC Clarification: Suture Removal Q&A

The spring 2013 Derm Coding Consult issue raised questions on the appropriate reporting and billing for suture removal. According to AMA CPT and the CMS, suture removal is included in the surgical package. It doesn’t matter if the surgical procedure has a 0, 10, or 90-day global period, the suture removal is included in the procedure. Only when sutures are placed by another practice or facility or physician that has no association (tax ID) with your practice then it is appropriate to report the suture removal. The question is how this is reported since there really is no CPT code.

The Coding Q&A shared a HCPCS code, S0630, Removal of suture: by a physician other than the physician who originally closed the wound. Although this S code could be reported, few carriers honor it, especially Medicare.

According to CPT Assistant, “Removal of sutures by other than the operating surgeon may be coded as a level of E/M service if suture removal is the only postoperative service performed.” When the sutures are placed by the same physician removing them there is no appropriate CPT code to report.

Now …

The AMA revised CPT code 15851 - Removal of sutures or staples requiring anesthesia (i.e., general anesthesia, moderate sedation), deleted CPT code 15850,and created two new add-on codes 15853-15854 for the removal of sutures or staples not requiring anesthesia (List separately in addition to an appropriate E/M service),which went into effect on Jan.1, 2023.

These add-on codes were created with the intent to capture and ensure remuneration for practice expense (PE) that is not included in a stand-alone evaluation and management (E/M) encounter that occurs after a 0-day procedure (e.g., services reported with CPT codes 11102 – 11107; 11300 – 11313) for wound check and suture removal where appropriate.These new add-on codes (15853, 15854) do not have physician work relative value units (RVUs) assigned to them because they are PE-only (i.e., clinical staff time, disposable supplies, use of equipment).

CPT add-on codes 15853-15854 are reported when the physician or non-clinician provider (NPC) removes sutures or staples WITHOUT the aid of sedation or general anesthesia. CPT code 15853 is reported for the removal of sutures OR staples and CPT code 15854 is reported when BOTH sutures and staples are removed. Codes 15853 and 15854 do not require anesthesia. These codes may be reported with an appropriate E/M service for any procedure that has a 0-day global period, if sutures or staples were placed.

Dermatologists may report CPT code 15853 -Removal of sutures or staples not requiring anesthesia (list separately in addition to E/M code) for wound check and suture removal where appropriate. As such, this code can be reported after any 0-day global procedure at which suture removal is performed in conjunction with an appropriate E/M service.

Because CPT codes 15853 and 15854 are add-on codes and should be reported with an appropriate E/M service code, no modifier is required to be appended to the E/M code. These codes can only be reported if an E/M service is also reported for the patient encounter.

Coding tip

Under normal circumstances, suture removal is an inherent part of any surgery performed and is included in the global surgery package. When the same, or another surgeon removes sutures under general anesthesia or moderate sedation (other than local), report 15851. Do not report 15851 for suture removal to access a prior wound or the same incision or for surgical access. Do not report CPT code 15853, 15854 for suture removal after a procedure designated with 10-day global package.

Coding example

Q: A patient had a 3-cm biopsy-proven, atypical, pigmented nevus removed from her shoulder. Because of the tension across the wound, the physician decided to leave the sutures in for 14 days. The lesion removal code reported (i.e., 11403) has a 10-day global period. When the patient returns on day 14 for wound assessment and removal of the sutures, may the physician report an evaluation and management (E/M) services code, and suture removal code 15853?

A: CPT code 11403, Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm, includes postoperative work to assess the wound and remove the sutures. Therefore, an E/M may not be reported just because this work occurred four days after the 10-day global period., CPT code 15853, Removal of sutures or staples not requiring anesthesia (List separately in addition to E/M code), may not be reported for removing sutures that were placed for a 10-day global procedure at any postoperative visit, during and beyond the global period because suture removal is inherent to and included in the practice expense for all 10-day global codes where sutures are placed.

Q: 10 days following a punch biopsy (CPT 11104) or an incisional biopsy (CPT 11105), the patient comes in for a separately identifiable reportable office visit or other outpatient evaluation and management service to examine a newly identified lesion.

During the encounter, suture(s) from the biopsy site are removed, pathology result(s) are discussed with the patient and a plan of action is formulated based on the clinicopathological findings.

You report CPT 15853 for the suture removal and an appropriate E/M code for the newly identified lesion evaluation and management.

A: Correct. CPT 15853 is an add-on code and can only be reported when a separately identifiable E/M service is also performed and reported on the same DOS.

Q: 12 days following a wide excision, the patient comes in for suture removal and pathology results. You discuss the results confirming an atypical, pigmented lesion, describe a long-term follow-up plan, self-monitoring, and the need/not for any lab/imaging studies. The sutures are removed, an excision for residual margins performed, and the defect is closed using the appropriate repair. Patient is reminded to schedule a three-month follow-up appointment.

CPT 15853 is reported for the suture removal and an appropriate E/M code for the discussion and action plan as well as appropriate CPT excision and repair codes.

A: Incorrect. CPT code 15853 is not reportable. Benign and malignant excision codes include post-operative wound assessment and suture removal. Discussion of pathology results and decision to excise additional margins is included in the excision code. Therefore, no E/M should be billed.

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