ED Coding and Reimbursement Alert

Size, location, and severity are all important factors.

Not a day passes without an ED physician seeing patients who require stitches to repair lacerations, and although many ED coders have the rules committed to memory, those regulations tend to change over time, requiring you to stay on top of the latest laceration repair directives.

Check out this lightning round of eight tips that can help you ensure that your laceration repairs are coded correctly.

Tip 1: First Consider Anatomic Location

Within each level of repair, CPT^® classifies wounds according to anatomic location. Note that these categories are not identical for each repair level.

Example:  For simple repairs, CPT^® groups the scalp, neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet) together as covered by 12001-12007.

For intermediate repairs, 12031-12037 describe layered closure of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet), while 12041-12047 apply for repair of wounds to neck, hands, feet, and/or external genitalia.

For complex repairs, the subclassifications are still more precise, with separate sections for trunk; scalp, arms and/or legs; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet, etc.

Tip 2: Evaluate Wound Severity

After you have determined the location of the wound, you must assess its severity. CPT^® classifies repairs as simple, intermediate, or complex, according to wound depth, with each category receiving its own code range.

Simple repairs are superficial wounds that involve primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures, according to CPT^®. Additionally, CPT^® stresses only simple, one-layer, primary suturing is required. Physicians will typically refer to these as single-layer closures. CPT^® code range 12001-12021 covers such repairs, which include local anesthesia and chemical or electro-cauterization of wounds left unclosed, according to CPT^®.

Intermediate repairs are more extensive and involve one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure, according to CPT^®. If the physician mentions layered closure, you probably have an intermediate repair.

A single-layer closure may qualify as an intermediate repair if the wound is heavily contaminated and requires extensive cleaning or removal of particulate matter. A common example of this is repair of road rash wounds that result from falling on gravel while riding a bicycle. CPT^® code range 12031-12057 describes intermediate closures.

Complex repairs involve more than layered closure, such as extensive undermining, stents, or retention sutures. If the physician mentions repair to the depth of muscle or deeper, it’s probably a complex repair.

Complex repairs are often reconstructive procedures and include creation of a defect to be repaired (for instance, excision of the scar and subsequent closure). Such repairs do not, however, include excision of lesions.

Coding for complex repairs differs slightly from coding for other wound repairs. With complex repairs, CPT^® assigns add-on codes for each additional 5 cm beyond 7.5 cm. You may bill multiple units of these add-on codes when necessary. Report complex repairs using code range 13100-13160.

To determine the level of repair, pay close attention to the operative report. Single-layer closures are generally simple unless the physician has noted extensive cleansing of the wound, in which case they may be intermediate. Dual-layer closures are considered as intermediate. Extensive revision or repair of traumatic lacerations or avulsions are considered complex.

Tip 3: Consider Closure

Before you can code for wound closure, you must determine if the wound repair or closure codes apply.

If the doctor determines that the severity of the laceration does not warrant stitches, staples, or tissue adhesive, and instead closes the wound using Steri-strips or butterfly bandages, you may report only the appropriate E/M service code, as supported by the chart documentation.

According to CPT^®, codes 12001-13160 designate closure utilizing sutures, staples, or tissue adhesive, either singly or in combination with each other, or in combination with adhesive strips.

Tip 4: Measure the Wound

In addition to severity (depth) and anatomic location, CPT^® groups repair and closure procedures according to the size (length) of the wound.

Example: Code 12001 describes simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet); 2.5 cm or less, whereas 12004 (… 7.6 cm to 12.5 cm) describes repair of the same severity and location, but of 7.6 cm to 12.5 cm length.

Remember: Reporting should be based on the size of the wound. Under the “Repair (Closure)” section, the first instruction for coding is to evaluate the size of the repaired wound. It is important to note that depending on the type of repair performed, some wounds will have a final defect size that is greater than the original defect size. Base your CPT^® code assignment on the documented wound size, which is typically performed after cleaning the wound and prior to repair.

Tip 5: Don’t Forget to Combine Similar Repairs When Indicated

After you have determined the location, length, classification, and means of closure for all individual repairs or closures, add together the lengths of the various wounds at each identical level of severity and classified anatomic location to arrive at a total length.

Tip 6: Consider the Global Period

Medicare rules for simple repairs can differ from those for intermediate and complex codes. Medicare changed the payment policy for simple laceration repairs starting almost a decade ago by shifting the global surgical package from 10 days to zero days. Since then, the follow-up visit for a wound check and suture removal is no longer included in the payment for suturing, stapling or using tissue adhesives on superficial wounds primarily involving the epidermis or dermis without deeper damage.

This change came about in part because Medicare officials did not believe it was typical for emergency department patients to return to the ED where the sutures were placed to have them removed 10 days later.

Tip 7: Follow-Ups Should Be Reported with ED E/M Codes

If a patient does return to the same ED for a follow-up visit for a simple repair wound check and suture removal, Medicare instructs you to use an ED E/M code to capture that service.

Example: A 72-year-old female returns to the ED for a wound check and suture removal 10 days after falling on a wet sidewalk, which required simple repair of a gash on her right knee. The emergency physician examines the knee wound, determines it to be well healed, and removes the sutures. Report this scenario with an ED E/M code, probably 99281 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a problem focused history; problem focused examination; and straightforward medical decision making…).

Tip 8: Ensure Whether Global Rules Apply

Remember that the zero-day global rule only applies to the simple repair codes, not to the intermediate or complex repair codes. For example, if you saw a patient that had both simple and intermediate lacerations repaired in the same visit, the service component of the return visit for the intermediate repairs would still fall under the 10-day global surgery package and not be separately billable. However, the work associated with the suture removal for the simple laceration would be reportable.