Encounter for removal of sutures 1 Z48.02 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. 2 The 2020 edition of ICD-10-CM Z48.02 became effective on October 1, 2019. 3 This is the American ICD-10-CM version of Z48.02 - other international versions of ICD-10 Z48.02 may differ.
Z48.0 ICD-10-CM Diagnosis Code Z48.0. Encounter for attention to dressings, sutures and drains 2016 2017 2018 2019 Non-Billable/Non-Specific Code. Type 1 Excludes encounter for planned postprocedural wound closure (Z48.1) Encounter for attention to dressings, sutures and drains.
We’ve spent the last two months reviewing the codes and guidelines for damaged skin treatment services by means of skin tag removal, shaving, and lesion excision. In this third and final installment, we’ll discuss coding for wound repair (closure) procedures using CPT® codes 12001-13160.
Wound dehiscence ICD-10-CM T81.30XA is grouped within Diagnostic Related Group (s) (MS-DRG v38.0): 919 Complications of treatment with mcc 920 Complications of treatment with cc
Disruption of wound, not elsewhere classified 1 T81.3 should not be used for reimbursement purposes as there are multiple codes below it that contain a greater level of detail. 2 The 2021 edition of ICD-10-CM T81.3 became effective on October 1, 2020. 3 This is the American ICD-10-CM version of T81.3 - other international versions of ICD-10 T81.3 may differ.
Use secondary code (s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Codes within the T section that include the external cause do not require an additional external cause code. Type 1 Excludes.
In other words, wounds requiring intermediate repairs are deeper than those requiring simple repair. Per CPT®, some single-layer closures may qualify as complex repairs, if the wound is “heavily contaminated” and requires “extensive cleaning or removal of particulate matter.”.
Some of these related procedures may not be separately reported; others may be separately reported, or separately reported only in specific circumstances. Here’s a quick rundown, based on CPT ® and the Medicare guidelines.
Wound repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions, but lesion excision may include would repair. Per CPT ®, simple repairs are always included in lesion excision, but “Repair by intermediate or complex closure should be reported separately.”.
Within each level of repair, wounds are classified according to anatomic location. Note that these categories are not identical for each level of repair. Scalp, neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet) (12001-12007) 3.
Often, the physician repairs several wounds in a single session. When multiple wounds are repaired, check if any repairs of the same classification (simple, intermediate, complex) are grouped to the same anatomic area. If so, per CPT® coding guidelines, the lengths of the wounds repaired should be added together and reported with a single, cumulative code. Do NOT combine wounds of different complexity or those that fall within separate anatomical location groupings.#N#When reporting wounds of differing severity and/or location, claim the most extensive code as the primary service and append modifier 59 Distinct procedural service to subsequent repair codes. Multiple procedure reductions will apply for the second and subsequent procedures, except for those reported using an add-on code.
Wound repair is often performed with other related procedures. Some of these related procedures can be separately reported, while others can’t or depend on specific circumstances. Here’s a breakdown of how to determine when separate reporting is warranted.#N#Never reported separately with wound repair:
If a physician only uses adhesive strips to close a wound, the repair must be reported using an E/M code ( 99201 - 99499) instead. The following steps will help you to code for a wound repair:
A 2.5 cm intermediate repair on the right shoulder, a 1.0 cm intermediate repair on the scalp, and a 1.0 cm intermediate repair on the left shoulder would be coded as12032, Wound Repair, Intermediate, 2.6 cm to 7.5 cm.
A patient has a 2.0 cm benign lesion removed from her neck. The physician also performs a 2.5 cm intermediate wound repair on the excised site. The physician’s services are reported as 11420 and 12001 -51.
Coding Excisions. An excision is the surgical removal or resection of a diseased part by an incision through the dermal layer of the skin , and may be performed on either benign or malignant skin lesions.
All simple wound repairs are included in the surgical package of the excision, and may not be reported separately.
With some excisions, it may be necessary to report more than one procedure code in order to capture the full services performed. When multiple surgical procedures are performed on the same patient, by the same physician, on the same day, during the same encounter, add modifier 51 (Multiple Procedures) to all subsequent procedures.
All excisions include a simple closure as part of the surgical package, and therefore, may not be billed separately. However, for excisions that require more than a simple closure, coders can report either an intermediate ( 12031 - 12057) or complex ( 13100 - 13160) repair, in addition to the excision.