Repairs are intermediate and complex. For instance, if you do something other than a simple repair with an excision of a lesion, then you do them separately and you would use modifier -51.
But that really is more of a payer issue nowadays. CPT says you should put it in there. But a lot of payers have their software system where it will order your CPT codes by value and then it will append the multiple procedure reduction on to the codes as they are showing up in their adjudication.
If RBRVS of the Medicare physician fee schedule said that these are under the multiple fee schedule reduction, then they will take the reduction and modifier -51 is not necessary anymore. For example, if the payer doesn't want it, lives in Illinois, and their Medicare carrier doesn't want modifier- 51. So, check with your carrier if they would like modifier -51 appended to the claim.
Whether they want it or and not, always list your CPT codes and RVU values. We don't code in the order that the physician provides the services. We code in RVU order keeping in mind the CPT Codes. So, we always want our most complex service to be the first service listed on the claim form.
When it comes down to coding information, what needs to be in the doctor's documentation is just the notice. For instance, in the simple repair, it says it's superficial. But for some people, it means only the epidermis. If they go any deeper, it has to be something more. But a simple repair involves the epidermis, the dermis or the subcutaneous tissue without significant involvement of deeper structures.
For a simple closure, the physicians just pull together the structure and then sew up the top of the skin across. But for the intermediate skin repairs – the buzz terms or the important thing to try to get your provider to put in your documentation is the fact that it was a subcutaneous tissue or the superficial, non-muscle fascia that they pulled together and had to sew that up.
Usually, non-absorbable sutures are used with the top of the skin pulled together to achieve the closure. So, the term you will see the physician use is, layered closure because they close it in layers.
If the physicians just say “The wound was closed in layers.” This is not enough as they should be describing it clearly because it's important that they get the subcutaneous tissue out there.
Another way to give yourself a heads up or a tip that such procedures are being done is by seeing two different kinds of suture material and the documentation of the Prolene and the nylon.
Seeing the different kinds of suture material is a tip off to the coder because if they do not see it, they need to go back to the physician and ask them what kind of closure was done. If it's a layered closure, there can be any addendum made to the record that's necessary and it can be coded properly as an intermediate repair. According to the latest medical audio conferences, the physicians can get the proper reimbursement and the additional reimbursements they deserve when they do that kind of closure.
When single layer closures can be actually done as intermediate, which is a CPT definition. But it's not usually done with excision of lesions. It is usually more when the laceration is coming down. With the complex skin repairs, you should look out for extensive undermining retention suture. Those are heavier sutures that are inside and are not made to be absorbable. So, they are made to stay there to hold the underlying tissue together so that the skin and the top part don’t collapse down.
When you see such things, especially the extensive undermining, depending on where on the body the lesion is excised (if it's somewhere where there's tight skin), they will have to extensively undermine around the area to loosen everything up enough to be able to pull it together to close it in the multiple layers. This is a complex repair. So make sure you're looking for the term “extensive undermining”, which is a big red flag for the coders as they should know a complex repair is being performed.
From a CPT perspective, each lesion and sutures should be coded separately unless you have two lesions clumped together and the physician takes them as one big excision. So, each lesion is coded separately but the skin repairs, a lot of times, are added together.
For more information on skin repairs, excision, medical coding at http://www.audioeducator.com/medical-coding-billing/urology.html