ED Coding and Reimbursement Alert

You can get simple laceration repair claims paid, but you may not obtain optimal and ethical reimbursement for the services. Double-check your operative reports and make sure you're accurately reporting simple laceration repairs, not downcoding more involved ones.

If you think you're downcoding procedures because of insufficient documentation, educate your physicians. Make sure they understand when they can document for a layered closure, says Sandra Soerries, CPC, CPC-H, director of healthcare compliance services for Tait Advisory Services in Kansas City, Mo. Physicians commonly document a simple laceration repair code for a service that actually required additional work. Inform your physician of the amount of money lost every time a layered closure goes to payers as a simple closure, she says.

Here are two examples of repairs under-reported as simple and how you can help the physician with documentation limitations.

Case #1: A 16-year-old student, riding home from school with a bottle of cologne in the side-pocket of his pants, crashes his bike and presents to the ED with a tear in his upper thigh. The ED physician does a fairly comprehensive E/M, considering the patient hit his head in the fall, and performs  a laceration repair, cleaning out large amounts of glass from the bottle that had shattered, and a layered closure.

Coding explanation: The physician marked his charge ticket as a simple laceration repair, which is incorrect, Soerries says. The repair in the example qualifies as an intermediate repair a multilayered repair that involves simple trimming or debridement. (Note that complex repairs involve "extensive" debridement, which includes preparation of the wound.) Even if the repair were single-layered, you would report an intermediate repair because of the heavily contaminated wound that requires considerable time to clean out glass shards. Report the appropriate code from the intermediate repair series for the extremities, 12031-12037.

Let your physicians know the appropriateness of using a more extensive laceration repair and the substantial difference in reimbursement for this specific case. Explain to them that physician documentation determines the code selection.

Case #2: A patient presents with a 6.5-cm laceration on the top of the foot that went into the muscle. The wound is an irregular flap laceration. The physician note documents "muscle, irregular, flap, contused tissue, irrigated extensive, wound explored, foreign material removed completely, debrided (minimal), wound margins revised."

Coding explanation: Even though this is a single-layer repair, the extra work with contamination and debridement justify an intermediate repair code. Report 12042 (Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm).