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Reimbursement Advisor

Is it “major” or “minor” dehiscence repair? ... No new code for new Depo-Provera formulation

April 2007 · Vol. 19, No. 04
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Is it “major” or “minor” dehiscence repair?

<huc>Q.</huc> I examined a patient at a routine postop visit and noticed that the surgical wound had split open. I brought her back into surgery the next day to repair the wound. Can I bill the postoperative visit in addition to the surgery if I attach a modifier -57?

<huc>A.</huc> CPT doesn’t have a hard and fast rule on this situation. But a modifier -57 (Decision for surgery) is generally reserved for more extensive evaluation of a patient whose problem results in a decision to do major surgery that day or the next. (“Major surgery” is any surgery that has a 90-day global period.)

You have 2 code choices. Surgery to repair wound dehiscence (Diagnosis code 998.32, Disruption of external operation wound) would be reported with:

  • code 12020 (Treatment of superficial wound dehiscence; simple closure), which has a global period of 10 days, or
  • code 13160 (Secondary closure of surgical wound or dehiscence; extensive or complicated), which has a 90-day global period.

Because the visit was scheduled as routine—by which I mean it appears that the patient did not realize there was a problem with the wound—it may be that you performed only a simple closure. In that case, it would be inappropriate to use a modifier -57. You should, however, add a modifier -78 (Return to the operating room for a related procedure during the postoperative period) to code 12020.

If, instead, dehiscence involved complex repair and you documented significant evaluation above and beyond normal postoperative care before determining that repair was necessary, you may bill that level of service with a modifier -57.

No new code for new Depo-Provera formulation

<huc>Q.</huc> Our practice has decided to purchase the new depo-subQ provera 104 (medroxyprogesterone acetate, 104 mg) for injection. Our coding staff can’t find a code for this product. Can you help?

<huc>A.</huc> Normally, you would report injection using a Healthcare Common Procedure Coding System (HCPCS) “J” code, but there is no code for this new product yet. That leaves you with 3 coding options:

  • Report J3490 (Unclassified drug), but also submit the National Drug Code (NDC) number to identify the injection
  • Report 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) and be sure to indicate the NDC number
  • Report the existing code for a noncontraceptive dosage of Depo-Provera (J1051) multiplied by a quantity of 2 (J1051 is for a 50-mg dosage).

I recommend that you use the last option only if the payer insists that you submit a “J” code for injection but will not accept the “J” code for an unclassified drug.

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