General Surgery Coding Alert

Question: Which is the appropriate code to report repair of an irregular, 5-cm laceration on the forehead involving subcutaneous tissue and muscle?


Tennessee Subscriber


Answer: From your description, this sounds like an intermediate-level wound repair, for which you should report 12052 (Layer closure of wounds of face, ears, eyelids, nose, lips, and/or mucous membranes; 2.6 cm to 5.0 cm).

During an intermediate repair, the surgeon usually closes one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin closure, according to CPT instructions.

Keep in mind: Layers alone do not determine the level of wound repair. You may also choose an intermediate repair code if the procedure involves extensive cleaning and debris removal, even if the closure involves only a single skin layer, according to CPT instructions.

A complex repair, however, requires more than just a multi-layer closure. If you wish to report complex repair codes (13100-13160), the documentation should make clear that the surgeon corrected a defect or performed extensive tissue debridement.

Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, charge capture manager for the University of Washington Physicians.