General Surgery Coding Alert

Question: An established Medicare patient reports to the surgeon's office after falling from the stairs on his front porch. He has a laceration on his lower right arm and complains of a headache.

The surgeon cleans the 2.7-cm wound on the patient's arm and makes a layered closure using sutures and Dermabond. The surgeon then performs a problem-focused history and examination on the patient to address his headaches. Can I report the Dermabond repair code in this scenario?


Missouri Subscriber


Answer: You should not include the Medicare code for Dermabond repair (G0168, Wound closure utilizing tissue adhesive[s] only). If your surgeon uses sutures or staples and Dermabond to close a laceration, you can report only the layered laceration repair code, and you should not report G0168.

On your claim, you should report the following:

- 12032 (Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 cm to 7.5 cm]) for the laceration repair

- 913.0 (Superficial injury of elbow, forearm and wrist; abrasion or friction burn without mention of infection) to represent the patient's arm injury

- E880.9 (Fall on or from other stairs or steps) to indicate the cause of the patient's arm injury

- 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making) for the E/M service

- 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 99212 to show that the E/M service and the repair were separate

- 784.0 (Headache) to represent the patient's headache

- E880.9 to verify the cause of the patient's headache.

Although E codes aren't required for Medicare patients, they provide supporting information and more completely describe the reason for the service.