Medicare Compliance & Reimbursement

On your laceration claims, be sure to prove that the physician provided care that qualifies for the laceration repair codes.

Medicare also has some different rules for certain repairs using Dermabond -- if you code these encounters as you would for a private payer, you'll likely end up with a denial.

Make sure service qualifies: When the physician treats lacerations, you might be tempted to flip to CPT's laceration repair section and choose a code. But before you do that, you'll need to make sure that the service meets the payer definition for a repair.

If the physician uses staples, stitches or sutures to close a wound, you can code laceration repair. But if the physician (or staff) uses only steri-strips, or some other kind of adhesive strip, to close the wound, you should consider the work an E/M service, says Kevin Solinsky, CPC, CPC-I, CPC-ED, president and CEO of Healthcare Coding Consultants LLC, Added Value Billing Inc.

Use an E/M code "when the adhesive strips are the sole repair material. If the adhesive is used in addition to sutures, staples or tissue adhesives, then report the appropriate [laceration] repair code," says Kevin Arnold, CPC, business manager for the Emergency Medicine Department at Connecticut's Norwalk Hospital.

Watch anatomy groupings: Next, you should check the body area being treated. CPT groups laceration repair by anatomical location -- with a twist.

The grouping of anatomical locations for repair codes "depends upon which type of laceration repair you are doing," says Holly Barrett, CPC, CPC-H, ED and outpatient surgery coder at Northeastern Vermont Regional Hospital in St. Johnsbury.

Check out these different anatomical breakdowns for laceration repair:

• Codes 12001-12007: Scalp, neck, axillae, external genitalia, trunk or extremities (including hands and feet)

• Codes 12011-12021: Face, ears, eyelids, nose, lips or mucous membranes.

• Codes 12031-12037: Scalp, axillae, trunk or extremities (excluding hands and feet)

• Codes 12041-12047: Neck, hands, feet or external genitalia

• Codes 12051-12057: Face, ears, eyelids, nose, lips or mucous membranes.

• Codes 13100-13102: Trunk

• Codes 13120-13122: Scalp, arms or legs

• Codes 13131-13133: Forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet

• Codes 13150-13153: Eyelids, nose, ears or lips.

Example: A patient with a simple 2.2-cm laceration on her nose presents to the physician. On the claim, you would report 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less).

Medicare exception: When coding simple repairs for Medicare patients, be on the lookout for Dermabond. If the physician uses Dermabond as the only closure material for a simple repair, report G0168 (Wound closure utilizing tissue adhesive[s] only) for the service.

This is for simple repairs only. If the physician performs an intermediate or complex closure with only Dermabond for a Medicare patient, report a laceration repair code from CPT.

Intermediate cuts are deeper: The rules regarding repair complexity are pretty straightforward. A simple laceration repair involves a single-layer repair without any significant particulate debris or contamination.

For instance, if the physician uses surgical staples to close a single-layer 7.4-cm cut on a patient's left leg, you would report 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 intermediate repairs, the physician must perform layered closure of one or more of the deeper layers of subcutaneous tissue and superficial non-muscle fascia in addition to the skin, Arnold says. You can also report an intermediate code if the physician performs a single-layer repair that is heavily contaminated and requires extensive cleaning or removal of particulate matter.

Warning: The simple laceration repair codes have some cleaning and particulate removal figured into their work units. Make sure your physician goes "above and beyond" this work before considering an intermediate code, Arnold says.

Example: A construction worker presents to the emergency department following a power saw mishap that caused a 3.2-cm forearm laceration into the subcutaneous tissue and superficial fascia. The emergency physician performs a level-three E/M, examines and cleans the wound, and performs a layered closure repair.

On this claim, report the following codes:

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

• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem focused history; an expanded problem-focused examination; medical decision-making of moderate complexity) 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) linked to 99283 to show that the E/M and the laceration care were separate services

• 959.3 (Injury, other and unspecified; elbow, forearm, and wrist) linked to 12032 and 99283 to represent the patient's injury

• E919.4 (Accidents caused by machinery; woodworking and forming machines) linked to 12032 and 99283 to represent the cause of the patient's injury.

Patients reporting for complex laceration repair are rare because these patients usually head to the operating room. On the other hand, your physician may perform a rare complex repair, so check out this explanation on the elements of a complex repair:

If the wound requires more than a layered closure, or the service includes scar revision, debridement of traumatic lacerations, or extensive undermining, it might be a complex repair.

When you use complex repair codes, be sure the physician includes documentation explaining why the repair was complex, experts say.