Answering a few questions will help you code correctly for laceration repairs (such as staples, sutures, or similar closure materials):
- Was the repair limited to the epidermis, dermis, and subcutaneous tissue, or did you need to probe more deeply?
Use simple repair codes for superficial wounds (epidermis and dermis) that need only a single-layer closure. If the provider fixed a deeper layer of subcutaneous tissue or superficial fascia, however, then assign intermediate repair codes. Remember that these codes do not include repairs to muscles. Such cases usually are referred to as surgical specialists.
- Where on the patient’s body was the repair made?
The codes within the simple and intermediate categories are further characterized by the location of the injury. For instance, refer to simple repairs on the scalp, neck, axillae, external genitalia, trunk, and/or extremities, the face, ears, eyelids, nose, lips, and/or mucous membranes.
- How long is the injury that was repaired?
Once you’ve identified whether the repair is simple or intermediate and what part of the body was injured, note the length of the wound. Providers often forget to outline this detail in their reports.
- How many wounds were repaired?
You can code for all of them. When the patient has multiple lacerations of the same repair complexity on the same body part, coding is easy: You simply add the lengths of each wound together and choose the matching code.
- How do I code for suture removal?
If a provider has placed sutures for a patient and the patient returns to the same provider for the suture removal, then the visit for the suture removal cannot be charged, because the removal is included in the initial laceration repair code.
Assigning the CPT for laceration repair depends on three things:
- The complexity of the repair (simple, intermediate, or complex)
- The anatomic location of the wounds closed:
Simple and intermediate category codes depend on the location of the injury. For instance, 12001–12007 refers to simple repairs on the scalp, neck, axillae, external genitalia, trunk, and/or extremities. Codes 12051–12057 indicate intermediate repairs of wounds to the face, ears, eyelids, nose, lips, and/or mucous membranes.
- The length of the wound closed (in centimeters):
For example, code 12001 should be assigned for a repair involving any of the relevant anatomical locations that are 2.5 cm or less, while code 12002 should be used for repairs that are 2.6 cm to 7.5 cm.
All the wounds repaired should be coded. If the patient had multiple lacerations of the same repair complexity on the same body part, the lengths of each wound should be added together to determine the code. A Medical Economics report provides the following example: a 5-cm cut on the left ankle and a 9-cm cut on the left calf would add up to 14 cm; code 12005 (12.6 cm to 20.0 cm) should be reported for a simple repair and code 12035 for an intermediate repair. Only repair lengths within a site can be added up. Lengths from different anatomic sites should be billed individually.
When more than one classification of wounds is repaired, the more complicated procedure must be always listed first. Modifier 51 should be added to the second procedure to indicate that multiple procedures were performed. The repair of a superficial wound that does not require sutures but is closed with adhesive strips is included in the fee for the evaluation and management (E/M) visit and should not be billed separately.
If the physician performed a deeply layered closure on the patient’s wound using staples for the method of repair, an intermediate repair code from the surgery section can be used. If the physician performed a single-layered closure only but had to perform extensive debridement in addition to the single-layered closure, therefore going above and beyond normal debridement, the intermediate repair code can be billed. A layered closure constitutes an intermediate repair and the intermediate repair code should be billed even if the physician does not specifically use the word “intermediate” in the documentation.
A complex repair code is used to bill the most complicated surgical repair that a physician will perform on the integumentary system, though complex repair excludes the excision of benign or malignant lesions. Complex repair is billed when the physician performs more than layered closure. Additionally, if a benign lesion was removed before the wound repair procedure, a minimum of two surgical codes can be billed: one for the removal and one for the repair.
The American Medical Association provides the following guidance on suture removal:
Removal of sutures by the physician who originally placed them is not separately reportable since the removal is included in the initial laceration repair code. On the other hand, if the physician who removed the sutures did not place the sutures, then the suture removal would be considered part of evaluation and management (E/M) and the E/M code can be billed.
Debridement is not considered a separate procedure and is usually treated as part of the repair procedure. However, debridement can be billed if the physician performs debridement on a day other than the wound closure procedure.
Medical coding outsourcing is a practical option to negotiate the maze of laceration repair codes and guidelines.
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Experienced medical billing and coding service providers will ensure accurate coding for laceration repairs by considering the complexity, location and subcategory, size, and whether multiple repairs were performed. Comprehensive physician documentation is vital to determine the complexity and size of the repair(s). As there is a considerable difference between the payment for the various repair types, lack of proper documentation can affect coding precision and the provider’s reimbursement.