Craking the Code 1

INTERMEDIATE AND COMPLEX REPAIRS 2020: PART 1

---

Cracking the Code

Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.

By Alexander Miller, MD, October 1, 2019

Tired of the status quo in CPT® coding? Need some shakeup in your surgical coding and documentation paradigms? Well, the CPT will do it for you in 2020. The intermediate and complex repair guidelines have been be revised for 2020 with the goal of providing clearer, measurable, and documentable guidelines and criteria for reporting intermediate versus complex repairs.

Why did this happen? After all, you may feel that things were going just fine: Procedures were being reported as per CPT guidelines and payments were being made by insurers for the billed services. Well, although payments were being made, those payments were skewing toward complex repairs, and the rate of complex repair billing has been consistently increasing. Such increases in costs to the health care system attract attention, particularly from Medicare. The resulting push, direct or indirect, is to flatten the rising utilization curve.

In the case of intermediate versus complex repairs, surgical excision repairs generate an overwhelming bulk of billing for intermediate and complex repairs. What is the typical distinction between an intermediate and complex repair? It is the performance of "extensive undermining." Presently, the CPT coding guidelines do not provide specific guidance as to what constitutes extensive undermining.' This lack of distinction created a concern about inappropriate upcoding to complex repair. As a result, the CPT Editorial Panel directed that a clear and measurable distinction between intermediate and complex repairs be generated.

Starting Jan. 1, 2020, we will have revised CPT introductory guidelines to the intermediate and complex repair section.

NEW INTERMEDIATE REPAIR GUIDELINES

(Revised language in italics): Intermediate repair includes the repair of wounds that, in addition to simple repair, 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. It includes limited undermining (defined as a distance less than the maximum width of the defect, measured perpendicular to the closure line, along at least one entire edge of the defect). Single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair.

NEW COMPLEX REPAIR GUIDELINES

(Revised language in italics): Complex repair includes the repair of wounds that, in addition to the requirements for intermediate repair, require at least one of the following: exposure of bone, cartilage, tendon, or named neurovascular structure; debridement of wound edges (e.g., traumatic lacerations or avulsions); extensive undermining (defined as distance equal to or greater than the maximum width of the defect, measured perpendicular to the closure line along at least one entire edge of the defect); involvement of free margins of helical rim, vermilion border, or nostril rim; placement of retention sutures. Necessary preparation includes creation of a limited defect for repairs or the debridement of complicated lacerations or avulsions. Complex repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions, excisional preparation of a wound bed (15002-15005), or debridement of an open fracture or open dislocation.

SUMMARY OF UPDATES TO CPT 2020: INTERMEDIATE AND COMPLEX REPAIRS

Intermediate repair

• Includes simple repair

• Requires layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia

• Includes limited undermining (defined as a distance less than the maximum width of the defect, measured perpendicular to the closure line, along at least one entire edge of the defect)

  • Example: Maximum width of defect perpendicular to line of closure: 2 cm

    • Less than 2 cm undermining done on one side of the line of closure (e.g., 1.5 cm)

• May constitute single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter

Complex repair

• Must meet requirements for intermediate repair (e.g., layered closure)

• Must also include at least one of the following:

  • Exposure of bone, cartilage, tendon, or named neurovascular structure

  • Debridement of wound edges (e.g., traumatic lacerations, avulsions)

  • Extensive undermining (defined as distance equal to or greater than the maximum width of the defect, measured perpendicular to the closure line along at least one entire edge of the defect)

    • Example: Maximum width of defect perpendicular to line of closure: 2 cm

      • Equal to or more than 2 cm undermining done on one side of the line of closure (e.g., 2.5 cm)

• Involvement of free margins of:

  • Helical rim

  • Vermilion border

  • Nostril rim

• Placement of retention sutures

Example 1: Will the simple repair guidelines change as well?

The simple repair guidelines will remain unchanged for 2020.

Example 2: One does a layered repair following extensive undermining of a cheek. New 2020 guidelines qualify this as a complex repair. What CPT code should be selected?

Once the repair type has been determined based upon the new 2020 repair code guidelines, select the appropriate CPT code from the simple, intermediate, and complex repair code series, all of which remain unchanged.

Example 3: You repair a nasal tip excision defect linearly and do a layered (3 cutaneous and 5 superficial sutures) 1.5-cm-long closure over visibly exposed lateral alar cartilage. You report CPT 13151.

Answer: Correct. Criteria for complex repair: layered closure, exposed cartilage have been met. Code selection is determined by location (nose) and repair length (1.1 to 2.5 cm).

Example 4: You excise a squamous cell carcinoma from an elderly woman's severely photodamaged, atrophic extensor forearm. You plan to repair the defect linearly. However, closure is a challenge, as the atrophic skin fails to support buried dermal stitches. Consequently, you close the wound with a series of retention sutures combined with several surface interrupted stitches to better appose the skin edges. Since you placed retention sutures you report a complex repair.

Answer: Incorrect. Placement of retention sutures alone does not qualify for a complex repair. One must also satisfy a criterion for intermediate repair, such as layered closure. In this case, no layered repair was done. Consequently, reporting of complex or intermediate repair is not appropriate. Report a simple repair.

Example 5: A patient comes in with a laceration suffered on pavement. You remove road debris and pavement particles from the wound and scrub out remaining debris. You then suture the wound with a single layer of interrupted stitches. You report an intermediate repair.

Answer: Correct. Although no layered closure was done, extensive particulate matter was removed from the particle-contaminated wound. This meets the definition of intermediate repair.

Sent from my iPhone

Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

Please excuse the shortness of this message, as it has been sent from
a mobile device.