ED Coding and Reimbursement Alert
When Length is Not Available
Ohio Subscriber
Answer: When the documentation does not have enough information to determine a correct code, you should ask the physician to supply an addendum with the needed information. This is addressed in the Office of Inspector General (OIG) model compliance plan for billing services. The addendum should indicate the date it was created and state that it is to supplement documentation of X date. Addendums are appropriate on occasion and are a pertinent part of the medical record. They are discouraged only if their use is limited to adding them after an audit process to provide the last bits of information to support a higher level of service.
If no documentation clarification is available, you should probably code it at the lowest of the available codes. Basically, if there is a laceration and the physician just states laceration repair and you dont know whether it was a foot long or 1 cm, you should probably code the one centimeter.
Part of the distinction between simple, intermediate and complex repair (12001*-13160) is based on the length of the laceration. If the length of the laceration is not provided, go with the lowest available code. For example, 12011* (simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less) vs. 12018 (over 30.0 cm).
In the example given, it would probably be classed at least as an intermediate repair with the extensive work that the doctor performed. If you have no other information to help determine the code, you should be able to support a low-level intermediate repair with what is stated in the example. It certainly isnt a simple repair.
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