A surgeon performed a complex closure for a procedure defined by one of the new soft tissue tumor codes found in the Musculoskeletal section of the CPT book. Our surgeon stated that she was heard that we could report a complex closure in addition to the surgical resection. We would like to verify if this is indeed true, and if so, does that mean any surgical procedure that requires complicated closure be billed separately.
Answer:
The new and revised soft tissue tumor codes brought with them very specific coding guidelines applicable to these codes only. According to CPT 2010,”Extensive undermining or other techniques to close a defect created by skin excision may require a complex repair which may be reported separately. Dissection or elevation of tissue planes to permit resection of the tumor is included in the excision.”
According to this definition, if a complex closure is required and is performed for reasons other than closure secondary to elevation of the tissue planes, the complex closure may be reported in addition to the surgical procedure.
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