General Surgery Coding Alert

Extent of repair will help to guide your code choice When your surgeon "explores" a wound, you may be looking at anything from a simple laceration repair to a full-on exploratory surgery, such as a laparotomy or thoracotomy. To make sense of the options, consider these expert-approved pointers. Look First to 20100-20103 In many cases, a code from the 20100-20103 range will be your best choice to describe wound exploration. Generally, explorations of this type occur when the patient experiences a "penetrating" trauma, such as a stab wound, gunshot, etc. Important: "You must ask yourself, -is this a penetrating wound?- If so, the wound exploration codes may apply. Codes 20100-20103 would never apply for blunt trauma, however," advises Terri Brame, CPC, CPC-H, principal at BEST Coders. As CPT describes, 20100-20103 can involve not only exploration but also: - "enlargement" of the wound, including extension of dissection, - debridement, - removal of foreign body(s), - ligation or coagulation of minor subcutaneous and/or muscular blood vessels, subcutaneous tissue, muscle fascia and/or muscle. "In the CPT guidelines for these codes, exploration and enlargement of the wound is just one in a list of procedures that may be performed under 20100-20103," Brame confirms. For instance, "Removing a foreign body from a penetrating wound falls under these codes, as would cleaning up the interior edges and inspecting for foreign body fragments on a through and through (entry and exit wound)," she continues. You should apply wound exploration codes according to the location of the wound the surgeon explores, as follows: - 20100 -- Exploration of penetrating wound (separate procedure); neck - 20101 -- - chest - 20102 -- - abdomen/flank/back - 20103 - -extremity. What to watch for: The surgeon should document the exploration, as indicated by his assessment of the damage, including damage to vessels and non-major structures, according to the AMA's CPT Assistant, June 1996. Example: Several small shards of metal become embedded deeply in a machine shop employee's upper leg as a result of an accident with a lathe. Using forceps, the surgeon removes the metal, looking carefully to be sure that he has removed all the foreign bodies. He then cleans and closes the wounds. In this case, you may report 20103 for the wound exploration and foreign body removal. Major Repairs Supersede Exploration If the surgeon repairs major structures or blood vessels, or if the surgeon must perform a more extensive opening via laparotomy or thoracotomy, for instance (in contrast simply to "enlarging" the wound), you would report only the specific repair code(s). "More precisely," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians (UWP) and Children's University Medical Group (CUMG) Compliance Program, "you [...]