pqri measure coding and reporting principles - Indiana Academy of ...

Various options exist for treating AKs. Clinicians should select an appropriate treatment based on the
patient’s medical history, the lesion’s characteristics, and on the patient’s preference for a specific
treatment. Commonly performed treatments for AKs include cryosurgery with liquid nitrogen, topical
drug therapy, and curettage. Less commonly performed treatments for AK include dermabrasion,
excision, chemical peels, laser therapy, and photodynamic therapy (PDT). An alternative approach to
treating AKs is to observe the lesions over time and remove them only if they exhibit specific clinical
features suggesting possible transformation to invasive squamous cell carcinoma (SCC).
Medicare covers the destruction of actinic keratoses without restrictions based on lesion or patient
characteristics.
WOUND REPAIR (CLOSURE) - CPT/HCPCS Codes 12001-13300 and G0168
These series of codes are used to describe laceration repair and, in limited situations, closure from a
procedure. Wound closure includes repair by sutures, staples, or tissue adhesives (e.g., 2-cyanoacrylate),
either singly or in combination with each other, or in combination with adhesive strips. Wound closure
utilizing adhesive strips as the sole repair material should be coded using the appropriate E/M code. For
Medicare claims when a wound is closed solely with tissue adhesive, physicians are instructed to use code
G0168, wound closure utilizing tissue adhesive only. Repair (closure) of most surgical wounds is
included in the allowance for the primary surgical procedure. However, for certain procedures, wound
closure may be separately billed.
Undermining the wound margins to permit closure is usually not separately billable using the
intermediate or complex wound repair codes.
When the wound repair codes 12001-13300 are used for closure of traumatic wounds, the CPT coding
guidelines should be followed.
Codes 20100-20103 are used to report exploration and repair of trauma wounds requiring Enlargement,
extension of dissection (to determine penetration), debridement, removal of foreign body(s), ligation or
coagulation of minor subcutaneous and/or muscular blood vessel(s) of the subcutaneous tissue, muscle
fascia, and/or muscle, not requiring thoracotomy or laparoscopy.
Bundling Of Repair Codes Into Excision Of Benign Lesion Codes
Payment for the excision of benign or malignant lesions of skin includes payment for simple repairs.
Separate payment for simple repairs (CPT codes 12001-12018) will not be made when reported with the
CPT codes for the excision of benign lesions (11400-11446) or the excision of malignant lesions
(11600-11646).
Medicare Bundling
For Medicare claims, payment for the excision of benign lesions with an excised diameter of 0.5 cm or
less (CPT 11400, 11420, and 11440) includes payment for simple, intermediate, or complex repairs. In
other words, separate payment for simple, intermediate, or complex repairs (CPT 12001-12018) will not
be made when reported with CPT codes 11400, 11420, and 11440.
Carriers use existing definitions for simple, intermediate, and complex repairs listed in the American
Medical Association's Physicians’ Current Procedural Terminology (CPT). For Medicare claims, payment
for the excision of a benign lesion with an excised diameter greater than 0.5 cm or the excision of a
malignant lesion of any size does not include payment for intermediate or complex repairs. Separate
payment for medically necessary intermediate repairs (CPT codes 12031-12057) or medically necessary
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*All CPT Codes, Descriptions, and Two-Digit Modifiers
Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01
Copyright 2007 Newby Consulting, Inc.