Internal Medicine Coding Alert

Published on Sun Jul 27, 2008 PDF

Question: A patient reports to the internist with two cuts on his right forearm: a deep 6-cm laceration near the elbow, and a 3-cm superficial laceration near the wrist. The physician preps and drapes the patient's arm, performs layered closure on the deep wound, and a single-layer closure on the shallow wound. Neither injury involved complication or tendon(s). Can I report two surgical codes for this encounter?

Tennessee Subscriber

Answer: You should report two surgical codes for this encounter. But because the physician had to prep only a single area for both procedures, you should include modifier 51 (Multiple procedures).

On the claim, 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 layered repair

• 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) for the single-layer repair

• 884.0 (Multiple and unspecified open wound of upper limb; without mention of complication) linked to 12032 and 12002 to represent the patient's injuries

• modifier 51 appended to 12002 to show that the repairs were separate.