General Surgery Coding Alert

Question: Please look at the following note and suggest the appropriate repair code for the case:

Wound repair of 3.5 cm subcutaneous laceration to palmar aspect of middle phalanx of left middle finger and palmar aspect of middle phalanx of left ring finger and palmar aspect of middle phalanx of left index finger. Linear shaped. Minimal bleeding noted. Gross contamination with debris. Distal neuro/vascular/tendon intact. Anesthesia: Digital block administered with 8 mls of 1% lidocaine. Wound prep: wound requires extensive cleansing with Betadine 500 ml X 2 and removal of debris, Wound explored extensively, copious irrigation. Skin closed with 26 4-0 Ethilon using simple sutures. Patient tolerated well.

Codify Subscriber

Answer: You should code this case as an intermediate repair (12042, Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 to 7.5 cm) for both fingers. Notice that in the note, the surgeon adds the repair lengths together (3.5 cm), which is appropriate because they are from the same classification and anatomical site.

If this were a simple repair, you would report the service as 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). But you’ll need to notice something else in this documentation if you want to get to the proper code.

Note cleansing: The op report for this case also describes “extensive cleansing … and removal of debris” and “copious irrigation.” CPT^® instruction states that you should report a single layer closure that requires extensive cleaning as an intermediate repair. Based on the documentation in this note, you should code the case as 12042.