ED Coding and Reimbursement Alert

Question: We received the following documentation of a laceration repair:
 
3.5-cm laceration of the chin involving subcutaneous, muscle, stellate, irregular. Sensation is normal, vascular intact. Anesthesia: lidocaine 1% local and prepped with hibiclens.
 Repair: Skin - #15 - 6-0 prolene

 SubQ - #8 - 5-0 Chromic

 Muscle/tendon - #4 - 5-0 Chromic.

How should we report this?      

Mississippi Subscriber


Answer: You should consider using code 12052 (Layer closure of wounds of face, ears, eyelids, nose, lips, and/or mucus membranes; 2.6 cm to 5.0 cm), because this repair meets the requirements for intermediate closure in several ways.
 
Per CPT, an intermediate repair involves layered closure of one or more of the deeper layers of subcu-taneous tissue and superficial (non-muscle) fascia, in addition to the skin closure.
 
CPT also states that extensive cleaning and removal of debris for even single-layer closures constitutes inter-mediate repair. Also, the additional non-skin layers closed are consistent with an intermediate repair.    

However, in order to consider a closure complex, you need more than just multiple layered closures. To code for a complex repair, look for documentation describing that in addition to layered closure, the repair required correction of a defect, or extensive debridement of tissue.