ED Coding and Reimbursement Alert

Watch for locations and classification before choosing your code.

The following wound repair presentations can help you understand when it is appropriate to com-bine the lengths of like repairs to report them under one code, says Todd Thomas, CPC, CCS-P, President of ERcoder, Inc. in Edmond, OK.

Example 1: A child was injured in a skating accident. The physician treats a 2.5-cm superficial cut on the left leg and a second 4-cm superficial cut on the right arm, closing the wounds with stitches.

Both repairs are simple and located on the extremities. Because the severity level and anatomic loca-tion fall within the same subcategory of codes (12001-12007), you must add the lengths together to arrive at a total of 6.5 cm. Consulting CPT®, the correct code for a simple repair of a 6.5-cm wound on the extremities is 12002 (... 2.6 cm to 7.5 cm).

Example 2: A hiker falls on a rocky trail, cutting his face (3 cm), both hands (3 cm and 5 cm), both arms (4 cm and 9 cm) and right leg (12 cm). All repairs are intermediate because the physician must remove debris from and thoroughly cleanse the wounds.

In this case, the wounds to the face, hands and arms and legs fall within different anatomic subcate-gories. For the face wound, report 12052 (Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm); for the hands, add together the 3-cm and 5-cm wounds for a total of 8 cm to report 12044 (Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm); and for the arms and legs, add together all wounds (4 cm + 9 cm + 12 cm = 25 cm) to report 12036 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 20.1 cm to 30.0 cm).

Look to 59 for Wounds of Different Severity at the Same General Location

Sometimes the location is similar but the class faction is different. In those cases, you should not combine the less severe wound into the higher classification code, even when they are in the same anatomical area referenced in the code descriptor, Thomas warns.

Example 3: A roofer falls while installing shingles at the edge of a two story house, catching and ripping the length of his arm on a sharp metal edge of his ladder resulting in a deep, jagged laceration, along with some less severe cuts on his trunk and legs from landing in recently trimmed bushes below.

The arm requires a complex repair 30 cm long. A 15-cm cut on the leg requires a two-layer closure, while another,
3-cm scrape on the same leg requires a few stitches. Likewise, a 5-cm laceration on the chest requires a simple repair.

In this case, report 13121 (Repair, complex, scalp, arms and/or legs; 2.6 cm to 7.5 cm) and +13122 (…each additional 5 cm or less [List separately in addition to code for primary procedure]) x 5 for the arm wound repair, 12035-51 (Repair, intermediate, wounds of scalp, axillae, trunk and/or ex-tremities [excluding hands and feet]; 12.6 cm to 20 cm; Multiple procedures) for the intermediate leg repair, and 12004-51-59 (Distinct procedural service) for the combined length of the superficial leg and trunk wounds.

Keep in mind that some payers will expect the 51 modifier on repairs of similar anatomic areas and also require the 59 for unrelated anatomic laceration repairs, though currently there are no CCI edits with these codes.

Adding modifier 59 to the last code specifies that the superficial wound(s) indicated by 12004 are separate and distinct from the intermediate leg wound indicated by 12035. Without modifier 59, many payers will bundle the simple repair with the intermediate repair of the same anatomic loca-tion. Since payer policies vary, your best bet is to check with the payer, says Thomas.