ED Coding and Reimbursement Alert

Question: A patient reports to the ED with three lacerations on their right arm. Two of the lacerations required simple repair: one measured 3.3 cm, the other was 1.9 cm. One of the lacerations required intermediate repair, and measured 2.7 cm. The ED physician decided to perform the laceration repairs after an ED evaluation and management (E/M) service that involved moderate-complexity medical decision making (MDM). What CPT^® codes should I report for this encounter?

North Dakota Subscriber

Answer: For this claim, report:

• 12031 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm) for the intermediate repair
• 12002 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm) for the simple repairs
• 99284 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making) for the E/M service

Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99284 to show that the physician performed a significant, separately identifiable E/M prior to the repairs

Explanation: Even though the physician fixed three separate wounds, two were in the same anatomic area and of the same complexity: the 3.3 cm and 1.9 cm simple repairs. Therefore, you’d add those two repair lengths up and choose one code based on that sum.

The intermediate wound, however, would need a separate repair code because the level of complexity was different than the other pair of wounds — even though it was in the same anatomic location.