ED Coding and Reimbursement Alert

Question: I've heard that physicians rarely perform complex laceration repair in the ED. Is this true? Also, is it appropriate to report a complex repair solely because the physician states "complex" in the patient's documentation?
    
Massachusetts Subscriber

Answer: Complex laceration repairs may not be performed every day in the ED, but that doesn't mean they're not a common coding issue. Confusion between complex and other repairs regularly causes reporting problems on ED claims.
 
Several factors may influence the percentage of these repairs, such as the location and acuity level of the ED, the availability of plastics or other specialists.
 
Even if the physician says "complex," there are still a few requirements that you should look for in the medical record that qualify the repair as such. For example, complex repairs require "more than layered closure," so the doctor should have performed at least a layered closure.
 
But you'll have to establish a higher degree of complexity than a regular layered closure, such as a more difficult repair technique. These techniques might be extensive undermining, stents, retention sutures, or creation of a defect. For instance, in the ED, the physician may repair a jagged stellate forehead laceration by excising it totally - leaving a larger elliptical wound that is easier to close and has better cosmetic results. You probably won't see these types of lacerations often in the ED.
 
Another crucial piece of the "complex" definition: The repair can involve "debridement of complicated lacerations or avulsions." Typically, this would include extensive undermining, resection of the wound edges, and debridement.
 
If you do report a complex laceration repair, you'll need to find the anatomic site of the wound and determine the length of the repair. Based on this information, you'll select a code from the 13100-13160 series. For example, if the ED physician coder performed a complex repair to a 2.0-cm wound on a patient's arm, you would report 13120 (Repair, complex, scalp, arms and or/legs; 1.1 cm to 2.5 cm). 
 
Or if the doctor performed such a repair to a 4.0-cm wound on a patient's nose, you would report 13152      (... eyelids, nose, ears, and/or lips; 2.6 cm to 7.5 cm). Keep in mind that the codes describe wound repair in groups: 1.1 to 2.5 cm, 2.6 to 7.5 cm, and "each additional 5 cm or less."