General Surgery Coding Alert
Compare Complex and Intermediate Closure
Question: Please help me code this note:
Treated 10 cm linear laceration of right forehead; performed saline wound irrigation and removal of multiple pieces of dirt and gravel. Applied lidocaine with epinephrine and repaired two layers: deep layers with simple interrupted absorbable 3-0 vicryl suture, and skin layer with staples 13.
Codify Subscriber
Answer: The correct code for the procedure is 12054 (Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm). You should code this as an intermediate repair because of the multiple layers and extensive cleaning.
Documentation of extensive cleaning can take you from simple to intermediate, but not from intermediate to complex. According to CPT®, a complex repair requires more than layered closure, such as scar revision, debridement for traumatic lacerations or avulsions, extensive undermining, stents, or retention sutures. The chart note offered does not reflect interventions such as debridement that would warrant a complex closure code.
Related Articles
General Surgery Coding Alert
- EVAT Case Study:
Missed Method and Site Could Cost Your Surgeon $600+
Coding by access site is key. If your general surgeon performs vascular procedures, such as [...] - ICD-10:
Location, Complications Expand Varicose Vein Options
Tell your surgeons to give more specific documentation. When you report lower-extremity varicose veins with [...] - ICD-10 Update:
You Might Avoid Claims Denials in the Implementation Year
Get to the right code family. You won’t be able to keep using ICD-9 beginning [...] - Focus on Diagnosis:
4 Tips Highlight ICD-10 Changes
Welcome combination codes and seventh digits. By now you should be familiar with basic changes [...] - You Be the Coder:
Don't Miss Combination Code
Question: The op note indicates that during a flexible sigmoidoscopy procedure, the surgeon discovered and treated [...] - Reader Questions:
Deal with New Medicare 'Opt Out' Process
Question: Our surgery practice has chosen to opt out of Medicare. I heard that there’s a [...] - Reader Questions:
Look for 'Separate Procedure' Bundles
Question: We have an op note that states that the surgeon injected air into the peritoneal [...] - Reader Questions:
Express Halted Surgical Procedure Using Modifier 53
Question: Our surgeon prepped and positioned a patient for repair of a recurrent inguinal hernia. But [...] - Reader Questions:
Account for Enterolysis Work
Question: The surgical note states that during a laparoscopic procedure, the surgeon encountered omental adhesions that [...] - Reader Questions:
Compare Complex and Intermediate Closure
Question: Please help me code this note: Treated 10 cm linear laceration of right forehead; performed [...]
