Layered Closure with Lesion Excision

Question:

Our practice performs many excisions of lesions with closures. My question is related to the closures. Is the provider documenting the closure in layers enough to report an intermediate repair if the tissue level is not?

Answer:

Great question!

We know that lesion excisions and closure with either intermediate and/or complex closure are appropriate to report together if the documentation supports it. In contrast, closure with simple repair is an included lesion excision and is not separately reportable.

The CPT guidelines are essential and should be reviewed carefully, as the definitions of each closure type can be found here. To report a closure accurately, it is best practice to include the type or level of tissue being repaired. KZA would encourage you to review the CPT guidelines for closures with your practice for documentation purposes. As you can see from the guidelines within CPT, the type and tissue level are factored into the definitions.

*This response is based on the best information available as of 3/13/25.

A Follow-up Question on Scar Revision

Question:

I reviewed your updated coding coach on scar revision and have a follow-up question. What if the scar was revised with an adjacent tissue transfer (ATT)?

Answer:

Thank you for your follow-up question!

Providing the requirements for reporting an adjacent tissue transfer (ATT) have been met and the adjacent tissue transfer is documented appropriately the ATT can be reported.

The CPT guidelines for adjacent tissue say that the term defect includes primary and secondary defects; the primary defect results from the excision, and the secondary defect results from the flap design.

The primary and secondary defects should each be documented separately in centimeters (cm); both measurements are added together to arrive at the total sq cm, allowing for appropriate code.

*This response is based on the best information available as of 2/27/25.

Non-healing Wound ICD-10

Question:

Should ICD-10 T81.31X– be reported for non-healing healing wounds?

Answer:

Thank you for your great question!

It would not be appropriate to report a non-healing wound with ICD-10 T81.31X, as this code is for the disruption of a closed wound.

There is no straightforward way to look up the ICD-10 code for a non-healing wound, either! That is because there is no specific code.

In this instance, ICD-10 T81.89X– would be assigned for the non-healing wound.

*This response is based on the best information available as of 2/13/25.

Is Scar Revision Still Complex Closure?

Question:

I have a scar revision for the abdomen and was going to assign CPT 13101. My coding teammate told me this is no longer the current coding recommendation. Is scar revision still reported with complex closure?

Answer:

Thank you for your inquiry!

Yes, your fellow coder is correct. At one point, CPT did include scar revision within the complex closure guidelines. However, in 2020, the guidelines associated with closures were changed, and scar revision was removed from the complex closure definition.

To address this change, a coding tip was placed within the CPT book in 2020 stating: “To report scar revision, see the Skin, Subcutaneous, and Accessory Structures, Excision-Benign Lesion subsection codes (11400-11471).”

According to CPT guidelines, scar revision is no longer reported with complex wound closure. Coding recommendations and guidelines are subject to change, so coders must review them and utilize up-to-date coding resources.

*This response is based on the best information available as of 1/30/25.

Donor or recipient site?

Question:

I’m a new plastic surgery coder and still learning. Are muscle flaps coded to the recipient site or coded by the donor site?

Answer:

Thank you for contacting KZA with your question. We understand that this can be confusing. According to CPT guidelines, muscle flap codes are selected based on the donor site.

*This response is based on the best information available as of 1/16/25.

Modifier 80 vs 82

Question:

What is the difference between modifier 80 and modifier 82 when a physician is acting as an assistant during surgery?

Answer:

While both modifier 80 and modifier 82 are used when a physician is actively participating as an assistant to a primary surgeon during a surgical procedure, modifier 82 is used in teaching or university hospitals that have approved Graduate Medical Education (GME) programs for Residents. In these teaching hospitals, there must be documentation indicating that no qualified resident was available to assist, to allow for another physician to act as the assistant surgeon, and then modifier 82 is appended to that assistant surgeon.

*This response is based on the best information available as of 1/2/25.