Internal Medicine Coding Alert

Question: A patient with a 1.5-cm laceration on his eyebrow presented to our practice. Our physician performed an intermediate repair. The patient also had a 3.6-cm forehead laceration that required a simple repair. Should we add these two wound lengths together and then code the intermediate repair, or does each get its own code?

New York Subscriber

Answer: In this instance, you should report code 12051 (Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less) for the eyebrow repair and 12013 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm) for the forehead repair.

Caution: You should only combine or add the lengths of like wounds when they're located in the same anatomic area and are of the same classification. In this case, you would report the intermediate repair separately from the simple repair.

Remember: You also need to report these two repairs separately because they are not the same  type of repair -- one is simple, and the other is intermediate.

If they were both simple or both intermediate lacerations and located in the same anatomic area, then you would add their lengths together and report one repair code reflecting the total length involved.

Since you are providing multiple procedures at the same encounter, you should also append modifier 51 (Multiple procedures) to the secondary procedure, which, in this instance, is 12013.