The words used in Common Procedural Terminology (CPT) are specifically defined, sometimes to the point of causing confusion for people who are not expert in their use. They are chosen to denote a specific medical concept across specialties. One such word is “repair” especially when used in the context of dermatology.
CPT has a number of codes, running between 12001 and 13160 that are used to describe integumentary wound repair. The word repair is used consistently throughout the text and definitions in this section of the CPT manual. If a billing person doesn’t have in-depth knowledge of the CPT language, may think of a repair as meaning the correction of a wound that is the patient’s chief complaint. In truth, emergency room physicians use wound repair codes on a daily basis.
A dermatologist should not be billing to close the excision he or she made to remove a dermal lesion. This does seem fair and reasonable. In everyday speech, “wound repair” has a different connotation than “excision closure.” After all, a surgeon doesn’t separately bill to staple a patient after an appendectomy. CPT disagrees in some incidences, and it does not differentiate between closure and repair.
At the introduction of the Repair codes, CPT defines repair in parentheses. The title of this code sub-set is actually: Repair (Closure). A simple repair of the wound created by the excision of a skin lesion is included in an excision code. CPT recognizes that simple closure is an expected component of a lesion removal. If a dermatologist breaks the skin, he or she should close the wound. More complicated repairs of the wound, however, are not an integral part of the expected procedure.
Without reading the text that introduces CPT codes 12001 through 13160, a medical professional who does not specialize in medical coding can be confused by the definitions CPT provides. While the introductory text uses the word closure to describe repair, the code listings use repair exclusively. The code definitions by themselves do not include the explanatory information included at the manual section’s introduction. A thorough reading and understanding of CPT terminology is just as essential to an accurately coded medical claim as a properly documented healthcare record.
CPT codes 12042 through 12047 are used to describe intermediate repairs of the neck, hands, feet and/or external genitalia. Just reading the code description does not tell a coder what an intermediate repair is. This is why medical coding, medical billing, and medical documentation review should be performed by certified coding and billing professionals. A professional medical biller or coder knows the difference between a simple repair and a simple closure: there is none. He or she knows that an intermediate repair of a wound entails layered closure of one or more deeper layers of subcutaneous tissues, in addition to the dermis and epidermis. Intermediate closure can also include a single-layer closure that entails excessive debridement.
The components of an intermediate repair are not normally an essential component of a lesion excision. For this reason, CPT does not bundle intermediate repair with the primary procedure, the way it does a simple repair. The majority of lesion excisions do not require intermediate repair. Alternatively, the medical record may not substantiate defining the wound closure independently.
Even less likely is a skin lesion excision that requires complex repair. CPT is even more precise when introducing the codes 13100 through 13160. The manual explicitly states that the excision of benign and malignant lesions are not included in these codes. They are expected to be reported separately from a lesion excision if a complex excision closure is required. A complex repair includes the services provided in simple and intermediate repairs in addition to extensive undermining, stents, or retention sutures.
It is unlikely that a dermatologist will frequently perform complex repairs in the regular office setting. If they do, the patient records must contain the relevant documentation to support the coding assigned and billed. Dermatologists who bill a higher than average percentage of complex wound repairs may expose themselves to increased scrutiny from third-party payers, including RACs.