ED Coding and Reimbursement Alert

The coders laceration repair challenge is searching the physicians documentation to determine whether the repair rates a simple, complex or intermediate code description. And, once thats done, the Medical Coder must further refine the choice by the length of the wound. The correct code requires both determinations because a long wound isnt always complex; a physician can perform a simple repair on a 30-cm wound.

CPT provides some guidance about using repair codes (see CPT Repair At A Glance on page 21). But applying these codes in real-life situations requires more
information. The following steps give you what you need to clear the confusion.

1. Make the distinction: intermediate vs. simple. A simple laceration repair includes trimming or removing fatty tissue and cleaning the wound, says Mandy Storman, RHIT, CPC, a coding consultant for Health Information Services at Eastern Maine Medical Center in Bangor, Maine. Once youve determined that the repair is simple, you would refer to codes 12001* through 12021 to choose the specific code by the length of the wound.

However, according to CPT, a single-layer closure of a heavily contaminated wound that needs extensive cleaning would elevate it to an intermediate repair. For example, an ostensibly simple repair that takes a physician 30 minutes to clean because its full of glass shards would be elevated to intermediate.

2. Make the distinction: intermediate vs. complex. An intermediate repair is a multilayered closure that involves simple trimming or debridement. Layered is the critical word. For example, a 3-cm-deep wound through several layers (epidermal and fascia) that requires deep sutures would be coded 12032* (layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 cm to 7.5 cm).

A complex repair includes extensive debridement within the layered closure. The word extensive is open to interpretation, so Storman offers an example. Extensive debridement might be pervasive road rash or a chainsaw laceration, with removal of particle matter and some extensive cleaning, she says. Inclusion of the term debridement in the documentation is unnecessary, providing it indicates time spent cleaning the wound and removing particle matter. CPT 2001s complex repair language also includes preparation of the wound: Necessary preparation includes creation of a defect for repairs (e.g., excision of a scar requiring a complex repair) or the debridement of complicated lacerations or avulsions. Complex repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions. For example, before repairing a jagged, contaminated laceration a physician prepares the site by making an elliptical incision around the cut and removing the devitalized or contaminated tissue.

3. Include debridement in the code or bill separately. In most cases, repair codes include debridement, so you would bill it as part of a procedure. But, if gross contamination requires prolonged cleansing, removal of a lot of contaminated tissue or when debridement alone is performed without immediate primary closure, CPT considers debridement a separate procedure. Coding for debridement alone requires documentation that clearly indicates the procedure was performed separately or that a repair was not performed. The documentation might state, large amounts of devitalized tissue dissected from the area of injury and grossly contaminated wound jet-irrigated extensively with 500 cc of saline. Within the excision and debridement code range (11000-11044), soft tissue or bone is coded 11040-11044, and 11010-11012 is used for repair of subcutaneous tissue or muscle.

4. Provide adequate, timely documentation for reimbursement. If the documentation doesnt indicate the length of the wound repaired or the type of suture material used, I go back to the physician. And, we dont bill it until we have all the information, says Kathy Schnautz, CMA, billing supervisor at Evergreen Clinic, a five-physician emergency-care clinic in West Branch, Mich. To avoid having a carrier kick back your original claim because of inadequate documentation, or question (or perhaps even consider fraudulent) a revised claim because youve added documentation in an untimely manner, provide physicians up front with detailed, code-oriented descriptions of laceration repairs.

Proper documentation helps coders choose a higher-paying code irrespective of the repair level. Repair code ranges are based on length, so if the length of a laceration is unknown, the coder must use 12001* (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less), which has a lower relative value than 12002* (... 2.6 to 7.5 cm), the code for the same laceration documented as 4.5-cm long.

The code for a complex repair of a 4-cm laceration is 13101 (repair, complex, trunk; 2.6 to 7.5 cm). But if the layers of closure and other procedural elements that comprise a complex repair are not in the documentation, the coder will have to use 12002*, which has a payment rate almost 10 times lower than 13101, says Susan Callaway CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.

5. Review repair method to help determine coding level.

Suture: If a repair involves two types of suture material, its most likely an intermediate repair, Storman says. For example, if a physician uses a dissolvable suture material in the subcutaneous tissue and a nonabsorbable suture on the skin that needs to be removed later, its obviously a layered closure and an intermediate repair.

Dermabond: Several questions arise with Dermabond: Include it with the repair codes? Report it separately? How does it affect the level of repair? When submitting to Medicare, if Dermabond is the sole form of closure, code it with HCPCS G0168 (wound closure utilizing tissue adhesive[s] only). However, if used with a layered closure, simply use the appropriate repair code. For non-Medicare patients you can use 12001* for sutures, staples or Dermabond because CPT does not have a specific code for tissue adhesives.