General Surgery Coding Alert

Because of the many variables involved in choosing wound repair/closure codes, and because payers can easily "check up" on such claims by reviewing the operative notes, surgeons must be especially careful to document carefully and completely.

In all cases, says Kathleen Mueller, RN, CPC, CCS-P, a general surgery coding and reimbursement specialist in Lenzburg, Ill., the surgeon should note the depth of each repair in simple terms and include the size of the laceration and anatomic area for each closure. Absent any of this information, documentation cannot support appropriate coding. For example, if the surgeon specifies only "repair of multiple lacerations" in the operative report, the coder can report only the lowest-level repair in any given category, leading to inaccurate coding and lost reimbursement opportunities. To make measuring the length of a wound simple, "make sure there are scalpel handles marked in centimeter graduations available," says M. Trayser Dunaway, MD, FACS, a general surgeon in private practice in Camden, S.C. Or, the surgeon can use a sterile tongue depressor or cotton swab to indicate measurements and compare them against a centimeter ruler after the procedure, he says.