Know Your Mohs, Part 2: The Closure
Background:
Once the Dermatologist has removed all the diseased tissue, the wound needs to be closed. Wound closures or repairs are categorized as Simple, Intermediate, or Complex. The determining factor for the type of closure billed is based on where on the body the wound is located and size and depth of the defect to be closed. If closure cannot be completed by a simple, intermediate, or complex procedure, adjacent tissue transfer or rearrangement may be used. Typically, closures for larger surface areas or more complex closures are reimbursed at a higher rate so we will focus on those.
Simple Repair Codes, >12.6 cm body surface area:
12005 to 12007 – scalp, axillae, external genitalia, trunk and/or extremities (including hands and feet)
12016 to 12018 – face, ears, eyelids, nose, lips and/or mucus membranes
Intermediate Repair Codes, >12.6 cm body surface area:
12035 to 12037 – neck, axillae, trunk and/or extremities (excluding hands and feet)
12045 to 12047 – neck, hands, feet and/or external genitalia
12055 to 12057 – face, ears, eyelids, nose, lips and/or mucus membranes
Complex Repair and Add-On Code, >12.6 cm body surface area:
13101 + 13102 – trunk
13121 + 13122 – scalp, arms and/or legs
13132 + 13133 – forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet
13152 + 13153 – eyelids, nose, ears and/or lips
Adjacent Tissue Transfer or Rearrangement, >10.1 cm body surface area:
14001 – trunk
14021 – scalp, arm and/or leg
14041 – forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet
14061 – eyelids, nose, ears and/or lips
14301 – any body area, 30.1 to 60.0 cm
14302 – any body area, each additional 30.0 cm
Guidelines:
- Wound closure utilizing adhesive strips as the sole repair material should be coded using the appropriate E/M code and may be present in a simple, smaller surface area close.
Common FWA Related Schemes:
- High volume billing of complex wound closures compared to peers
- High utilization of adjacent tissue transfers or rearrangement compared to peers
- High volume of larger body surface areas compared to peers
- Utilization of 14301 and 14302 by a plastic surgeon for any diagnosis related to weight loss, or post weight loss surgery which would be considered cosmetic in nature and may not meet coverage criteria
The Codoxo Forensic Platform and the Schemes entry point can assist your plan with identifying potential issues with wound closures using the following widgets and user selections:
Schemes, Top Specialties, Codes viewpoint identifies providers with outlier ‘wound closure’ utilization
Schemes, Top Detection Categories identifies outlier provider utilization of ‘wound closures” using AI detectors, specifically Frequent Combinations, Suspicious Trends, Time Behavior, PTP Edit Violations, MUE Violations and Upcoding.
We recommend health plans assess their overall payments and utilization for simple, intermediate, and complex closures using the repair codes listed above through the Query, Aggregates tool.
In addition to the AI detectors, the Query toolkit allows users to identify outlier utilization of adjacent tissue transfers across all claims using the following criteria:
Claim Type = Professional
Run Queries Over = Aggregates
Aggregate By = Rendering
Code Type = Procedure
Rendering Specialties = Select All
Procedure Code, These = (14001, 14021, 14041, 14061, 14301, 14302)
Provider Payment Received, Within this Range, Minimum = 1
References:
- CPT Manual (AMA Version) pages 107 to 110
If you are interested in learning more about Codoxo’s forensic AI platform or would like to speak to Codoxo team member, contact us via info@codoxo.com.