# Laceration Documentation



## alisonbee (Mar 30, 2010)

*This note is from the Physical Exam:
UPPER EXTREMITY *
 More prox one is 5 cm in length, wide and gaping through fatty tissue. Goes across vertical strips of his tattoo. There are mult pieces of metal as well as pieces of tattoo ink within lac. The more distal lac is 2 cm in length, not as deep, and straight edged rather than jagged.,

*From the laceration note:*
Foreign body identified, Wound contaminated, debris was metal. Intermediate repair of, right arm laceration, total length 7.0cm, Skin layer closed with 4.0, Nylon, Interrupted, 10 stitches/staples, Subcutaneous fascia closed with 5.0, Vicryl, 4 stitches, Wound well approximated, Abx ointment applied, Dressing applied, Tetanus ordered, The larger lac was done as a layered closure. All the debris was easily picked out. The lines of the tattoo were well lined up. The smaller, distal lac did not require a layered closure.

*From MD notes:*
2 arm lacs repaired

Question:  Does all of the information need to be contained within the laceration note to be coded appropriately?  Or is it okay to "piece" together the information documented to achieve the appropriate coding?

Coding suggested:  12032, 12001

I appreciate any input.  Thank you


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