ED Coding and Reimbursement Alert

Question: A patient with a laceration on the inside of her mouth reports to the ED; the wound is bleeding, but a level-two E/M reveals that the cut is entirely inside the patient's mouth. The nurse practitioner (NP) stops the bleeding with gauze and some light pressure. Then the ED physician closes the 2.3-cm cut using sutures. We reported 12011 and our internal compliance office questioned the code. Why?

Minnesota Subscriber

Answer: This is an example where you can measure the coding in degrees of accuracy. While the mucous membrane repair descriptor is not fully incorrect, there is a more specific code for the service. A better choice for this encounter would be one of the vestibule of mouth repair codes (40830-40845). When you re-submit the claim, report the following:

- 40830 (Closure of laceration, vestibule of mouth;

2.5 cm or less) for the repair

- 99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity ...) for the E/M

- modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99282 to show that the repair and E/M were separate services.

While 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less) might have seemed like the correct choice, 40830 is more accurate because the injury was entirely contained on the inside of the mouth.

If the physician had repaired the same wound on the patient's lower lip, for example, you would report 12011 for the service.