Careful distinction can prevent surgical coding errors

Part 2 of a two-part series on common CPT coding errors focuses on trauma resulting in surgery and the differences in orbitotomies.

Riva Lee Asbell

In Part 1 of the series, the principle causes of faulty surgical coding were reviewed, including the use of unlisted Current Procedural Terminology codes and the differentiation between coding for foreign body removal and implant removal.

In Part 2, some more of the most prominent clinical examples are presented that involve trauma resulting in surgery and the differential in orbitotomies.

Wounds vs. lacerations vs. dehiscences vs. perforations

A wound, as defined by Merriam-Webster’s dictionary, is an injury to the body consisting of a laceration or breaking of the skin or mucous membrane, usually by a hard or sharp object. It also has another definition: an opening made in the skin or a membrane of the body incidental to a surgical operation or procedure.

A laceration is a traumatically induced event that results in an external opening of skin and mucous membrane, often described as a jagged wound. Ophthalmic laceration repair codes are found in both the “Eye” section and “Integumentary” section of CPT.

They include:

• CPT Repair codes 12011-12018; 12051-12057; 13150-13153
• CPT Adjacent Tissue Transfer or Rearrangement codes when applicable 14060-14061
• CPT 67930 and 67935 (partial thickness and full thickness suture of wound)

Examples of procedures that should not be coded as laceration repair include resuturing of incisional site after upper eyelid blepharoplasty and repair of broken frontalis sling.

A dehiscence is a bursting open or parting of the lips of a surgical wound. Generally, the area has been sutured previously.

Repair of a wound dehiscence should not be coded as a laceration repair. Use the following CPT codes when applicable or the unlisted code, if necessary:

• 12020 Treatment of superficial wound dehiscence; simple closure
• 12021 Treatment of superficial wound dehiscence; with packing
• 13160 Secondary closure of surgical wound or dehiscence, extensive or complicated

A perforation, such as occurs with corneal ulcers, is caused by a disease process with penetration of a surface and should not be coded as a laceration repair.

Example: The use of glue for repair of a perforating corneal ulcer. There is no CPT code for application of glue to the cornea to treat this condition. CPT code 65286 for repair of a corneal laceration using glue is not correct, and you should use the unlisted code.

Orbitotomy vs. osteotomy

There are basically two sets of orbitotomy codes in the “Eye” and “Ocular Adnexa” section of CPT.

In CPT, all of the code descriptor up to the semicolon pertains to the first code listed as well as the subsequent codes that are indented, and the first word is not capitalized.

The first set of codes (67400, 6405, 67412, 67413 and 67414) has the following preface: “Orbitotomy without bone flap (frontal of transconjunctival approach).”

The second set of codes (67420, 67430, 67440, 67445 and 67450) begins with “Orbitotomy with bone flap or window, lateral approach (eg, Krönlein).” The definition of the surgery for this set of codes involves the use of an oscillating saw to remove bone as the surgical approach, not as part of the procedure. Removal of bone may also occur as part of the procedure if an osteotomy, decompression or other bone removal is performed. However, if a “window” of bone was not removed in order to perform the operation, then this set of codes should not be used.

Just because bone was removed during the surgical procedure does not entitle the coding of the procedure as an orbitotomy with bone flap.

In summary, it behooves surgeons to understand CPT nomenclature when selecting codes in order to remain in compliance with Medicare regulations while optimizing reimbursement.

Reference:

• CPT codes, copyright 2010, American Medical Association.

• Riva Lee Asbell is president of Riva Lee Asbell Associates, an ophthalmic reimbursement consulting firm, and a clinical assistant professor of surgery (ophthalmology) at the University of Medicine and Dentistry of New Jersey/Robert Wood Johnson Medical School at Camden. She can be reached at RivaLee@aol.com; website: www.RivaLeeAsbell.com.