ED Coding and Reimbursement Alert

Accounting for depth is a tricky task when coding closure.

Practices interested in $80 or more for the same closure repair need to walk the line that separates simple from intermediate.

Check out part II of our wound care FAQ for all the facts on ferreting out those higher-paying intermediate repairs.

What Makes a Repair "Simple"?

A wound closure is a simple repair if the procedure:

• is simple;

• is a single-layer closure involving the epidermis, dermis, or subcutaneous tissues; and

• does not involve deeper structures.

Code these closures with 12001-12021, confirms Dilsia Santiago, CCS, CCS-P, a coder in Reading, Pa. And remember that simple repair includes "local anesthesia, and chemical or electrocauterization of wounds not closed," she continues.

Example: The ED physician examines a 22-year-old patient's scalp wound.

Utilizing prolene sutures the physician closes a 2.3 cm single-layer wound. On the claim, you'd report 12001 (Simple repair of wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) for this encounter.

Simple, Intermediate: Does It Really Matter?

If you're interested in more money for the same service, knowing the difference between simple and intermediate repairs is vital.

Example: Let's say the ED physician closes a 2.9 cm laceration on a patient's forehead. You report 12013 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm) for the service; encounter notes justify an intermediate repair because the physician needed to perform layered closure of the wound, however, so you should have opted for 12052 (Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm).

Payout: The wrong code here will cost you about $90. The 12013 code pays about $111 (3.08 transitioned facility relative value units [RVUs] multiplied by the 2009 Medicare conversion rate of 36.0666). You'll corral about $191 for 12052, however (5.08 RVUs multiplied by 36.0666).

OK, How Do Simple and Intermediate Differ?

Simple repairs involve only the epidermis, dermis, and subcutaneous tissues; intermediate repairs also involve the superficial fascia (non-muscle).

Code these closures with 12031-12057, says Santiago.

Good tip: When looking at the encounter notes, if coders can tell that the physician is "in the fascia, then it's not simple but intermediate," says Santiago. There are two main types of  intermediate repair scenarios. In the first, the notes typically indicate that the physician performed a layered closure of a deeper area on the patient's wound.

"Depth is best reported by anatomical level instead of measured distance," says Jeffery Linzer, MD, FAAP, FACEP, associate medical director for compliance for the Emergency Pediatric Group at Children's Healthcare of Atlanta at Egleston.

Type 1 example: The ED physician performs a levelthree E/M service for a patient with an open cut on his forearm. Notes indicate that the injury "penetrated the dermis, through to the fascia. No infection present." Using a layered repair the physician closes the deeper tissues with vicryl and the skin with nylon sutures as part of 2.6 cm repair; she then dresses the wound.

This is an intermediate repair due to wound depth. On the claim, report the following:

• 12032 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 cm to 7.5 cm) for the repair

• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) for the E/M

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99283 to show that the E/M and repair were separate services.

What About Single-Layer Intermediate Fixes?

If documentation reveals that the physician performed a single-layer closure, but he had to perform extensive cleaning or removal of particulate matter, this may also constitute an intermediate repair. To ensure coding consistency, check with your physician and fellow coders to come up with a definition for "extensive" removal of particulate matter.

Type II example: The ED physician performs a levelthree E/M service for a patient who slipped on the ice and cut his left hand on a snow shovel; he was using the shovel to spread rock salt at the time of the accident, and there are bits of gravel and rock salt in the open wound, causing the patient extensive pain. After the physician orders pain medication, he performs extensive debridement using a scalpel to scrape out the salt and gravel, then performs 2.9 cm single-layer closure on the wound.

This is also an intermediate repair. On this claim, report 12042 (Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm) for the closure and 99283-25 for the E/M.

Documentation tip: "The physician does not need to specifically use the word ‘intermediate' to bill for an intermediate repair. A layered closure constitutes an intermediate repair; the physician may document that a layered closure was performed," says Santiago.