ED Coding and Reimbursement Alert

Evidence of debridement often leads to intermediate fix code.

The ability to tell the difference between an intermediate laceration repair and a simple one is vital for the coder that wants to recoup all earned reimbursement for these claims.

Why? Laceration repairs are common in the ED, comments John Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop and Associates. Further, intermediate laceration repair codes pay at a higher rate than simple ones.

For example, let's say your ED physician repairs a 5.2-cm scalp laceration. You decide to report 12002 (Simple repair of superficial wound s of scalp, neck, axillae, external genitalia, trunk, and/or extremities [including hands and feet]; 2.6 cm to 7.5 cm) for the encounter, but the notes would have supported an intermediate code (12032, Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 cm to 7.5 cm).

Breakdown: Code 12002 pays out at about $70 per encounter (2.08 transitioned facility relative value units [RVUs] multiplied by the 2011 Medicare conversion rate of 33.9764). The 12032 code pays about $195 per encounter (5.74 transitioned facility RVUs multiplied by 33.9764.)

Use this expert advice for full laceration repair pay:

Choose simple code for most single-layer repairs

In most basic terms, laceration repair categories are broken down thusly:

Simple " single layer, no particulate, no contamination.

Intermediate " two layers, or single layer with heavy particulate and/or contamination that requires extensive cleaning or removal of debris.

Complex "Repairs requiring more than layered closure including scar revision, debridement, extensive undermining or retention sutures

If the otherwise simple wound repair is heavily contaminated with debris and requires extensive cleaning or removal of particulate matter, then the repair might qualify for an intermediate repair code, says Kevin Solinsky, CPC, CPC-I, CPC-ED, president and CEO of Healthcare Coding Consultants LLC, Added Value Billing Inc. in Gilbert, Ariz.

Do not just assign an intermediate repair code each time encounter notes indicate debris removal or irrigation, experts warn.

"Of note is that most lacerations will have some degree of particulate matter removed," explains Kevin Arnold, CPC, director of compliance for Washington state-based LYNX Medical Systems. "But in order to assign an intermediate repair, the work involved in removing the matter must be extensive and above what is considered normal removal or cleaning."

Example: A patient presents to the ED after an accident while chopping wood; notes indicate he's got a 7 cm gash in his right thigh that penetrates into the superficial fascia. The ED physician cleans and numbs the wound area, and repairs it using layered sutures (first in the superficial fascia, then in dermis and epidermis). The physician checks the patient's tetanus status, which is up to date, and applies antibiotic cream. Notes indicate a level three ED E/M service accompanied the repair.

For this encounter, you'd report the following:

Observe Documentation Rules for Intermediate Claims

When filing your intermediate laceration repair claims, be sure to include documentation that identifies the length of the repair, advises Joan Gilhooly, PCS, CPC, CHCC, a coding expert and president of Medical Business Resources in Lebanon, Ohio. Insurers want the length of the repair, not the estimated diameter of a wound.

In addition to including documentation reflecting repair length, Bishop recommends you document the mechanism of injury (blunt sheer, puncture, etc.) and type of wound (stellate, flap, curved).

"This documentation can support the complexity of repair," Bishop says.