Pediatric Coding Alert

Are you having trouble piecing together the information you need to report laceration repairs accurately? Its not that difficult that is, if you know what to document.
 
Coding experts offer the following six tips that will help you sew up any holes in your laceration repair billing and improve your reimbursement.
 
1. Determine the Method of Closure

Your first step is to identify the method(s) used to close the wound. For repairs with sutures, staples or tissue adhesive (Dermabond), either singly or in combination with each other, you would report a code in the 12001-13160 range, according to CPTs introduction to laceration repair. 
 

If the pediatrician uses adhesive strips (Steri-strips) as the sole repair material, you would not code this as a laceration repair, CPT says. Regardless of the classification, size or site of the wound, if applying a Steri-strip is the only repair, bill only an E/M code (99211-99215), not a repair code, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.
 
Expect the E/M service for Steri-strip application to be at a low level, Callaway adds.
 
For example, a 5-year-old girl falls on a playground and cuts her leg. The pediatrician determines that the wound does not warrant stitches, staples or tissue adhesive and instead closes the laceration with Steri-strips or a butterfly bandage. In this instance, you would report CPT 99213 or higher, depending on how much time the physician spent evaluating the trauma and repairing the wound.
 
2. Check Notes for Wound Severity

Next, youll need to determine whether the repair is simple, intermediate or complex based on the procedure documentation.
 
Physicians should prepare a separate laceration repair note, apart from any E/M documentation, that describes the laceration, any debridement required, the number of layers repaired, and the repaired length, says Jeffrey Linzer Sr., MD, MICP, FAAP, assistant professor of pediatrics at Emory University and EMS coordinator at Childrens Healthcare of Atlanta and Hughes Spalding Childrens Hospital.
 
Use a code in the simple repair range (12001-12021) when the pediatrician documents that the wound is superficial, involving primarily the epidermis or dermis or subcutaneous tissues and requires a single-layer closure, CPT states.
 
For intermediate repairs, report a code in the 12031-12057 range when the physician indicates that the laceration required closure of one or more deep layers of subcutaneous tissue, in addition to the epidermal/dermal closure, according to CPT. 
 
Complex repairs (13100-13160), which are not likely in an ambulatory pediatric practice, involve complicated, multiple-layered closures and are often reconstructive procedures. These closures generally involve muscle or tendon repair, and a sub-specialist usually performs them, Linzer says.

Avoid Undercoding Intermediate Repairs

Dont make the mistake of reporting a simple repair code when the pediatrician actually performs an intermediate-level closure, or you could be forfeiting hard-earned pay, coding experts say.
 
Indeed, the most common error coders make in reporting laceration repairs is not realizing that the intermediate category can include layered or extremely dirty simple wounds, Callaway says. Moreover, if the pediatrician documents that he or she performed extensive debridement as part of a simple repair, you can use a code from the intermediate laceration category to report the service, she adds.
 
For instance, a 10-year-old boy falls while riding his bike and cuts his arm. The physicians note indicates that the boy had a 3-cm simple laceration of the arm, which was contaminated with oil and debris from the street and required extended cleaning. You would report 12032 for intermediate repair to the arm instead of 12002 for simple repair of the arm. The physician should clearly document the extra work required to clean the wound to justify the intermediate classification for a single-layer repair, Linzer says.
 
You would bill debridement (11040-11044) as a separate procedure only if it is extensive, the wound is very contaminated, or the physician performs only debridement without a primary closure, Linzer says.

3. Get the Location Right

The laceration site helps determine code selection, so make sure you can identify information on this in the procedure note, Callaway says.
   Simple repair (12001-12021) includes two basic groups: 12001-12007 (scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]) and 12011-12018 (face, ears, eyelids, nose, lips and/or mucous membranes).
  Intermediate repair includes three groups: 12031-12037 (scalp, axillae, trunk and/or extremities [excluding hands and feet]); 12041-12047 (neck, hands, feet and/or external genitalia); and 12051-12057 (face, ears, eyelids, nose, lips and/or mucous membranes).
  Complex repair includes five groups: 13100-13102 (trunk); 13120-13122 (scalp, arms, and/or legs); 13131-13133 (forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet); 13150-13153 (eyelids, nose, ears and/or lips); and 13160 (secondary closure of surgical wound).
 

The repair groupings are not identical for each level, so read the code description carefully to avoid confusion.

4. Add Up Repairs According to Site and Severity

In addition to laceration site, choose the correct repair code according to the length of the repair (noted in cen-timeters [cm]) not length of the wound, Linzer says.
 
If a pediatric patient has a mixture of simple (12001-12021) and intermediate (12031-12037) repairs, code intermediate repairs before coding simple ones, and group like repairs together, Linzer and Callaway say. In essence, you should report the total repaired length for like repairs in like locations, Linzer says. CPT treats all wounds at the same level of severity and anatomic subcategory as a single cumulative wound, coding experts say.
 
For example, if the pediatrician indicates that a patient has a 1-cm intermediate laceration on the cheek and a 2-cm intermediate laceration on the forehead, you would add the two procedures and report the service as a 3-cm intermediate face laceration repair (12052), Linzer says.
 
On the other hand, if the pediatrician documents a 1.5-cm intermediate laceration repair to the cheek, a 2-cm simple repair to the forehead, a 4-cm intermediate repair to the leg, a 2-cm intermediate repair to the forearm, and a 3-cm simple repair to the forearm, the correct order of coding would be, according to Linzer:
  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 6-cm intermediate repair to arm/leg
  12051* face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less for the 1.5-cm repair to the cheek
  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 3-cm simple repair to the arm
  12011* face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less for the 2-cm simple repair to the forehead.
 
Rank the codes by severity (intermediate, then simple), and within those groupings, by length (longest repair first, shorter ones second), Linzer says.
 
Also, append modifier -51 (Multiple procedures) to subsequent (secondary) procedures that follow the most complicated or primary repair when reporting more than one repair code per session, Callaway says. The reason for this order is that payers reduce reimbursement by 50 percent for subsequent codes with modifier -51 appended, so you should list the most complex code with the highest relative value units first (12032). In the case above, you would append modifier -51 to 12051, 12002 and 12011 to indicate to payers that the physician performed subsequent repairs.

5. Report Additional E/M Services 

In many instances, the pediatrician will perform E/M services that are separate from the laceration repair. You can bill for an E/M service if it is distinct from the laceration repair, Linzer says. If, for instance, a child falls and cuts himself, and the pediatrician performs an evaluation to determine possible injuries other than the laceration, you would report an E/M code (99211-99215, established patient office visit) if the physician clearly documents the E/M service, he says.
 
When lacerations are the only pertinent physical findings of an E/M evaluation, link the appropriate ICD-9 code for the laceration (depending on the site) to the repair code, Linzer says. 
 
If the pediatrician finds other problems besides the laceration, such as a minor head injury or contusions, you should report those diagnoses, linked to the E/M code, in addition to the codes for the laceration repairs, Linzer says.
 
Be sure to add modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to indicate that the physicians E/M work is a separately identifiable service, Linzer adds.
 
Because some laceration repair codes are starred procedures, any E/M service you report with them must have modifier -25 appended.
 
Heres an illustration: A 1-year-old boy just learning to stand pulls a dining-room chair on top of himself, causing a small laceration on the forehead. The pediatrician sutures the wound and also checks the child for other signs of head trauma, performing a thorough neurological examination. In this situation, the laceration to the head becomes secondary to the evaluation for head trauma, says Peter Rappo, MD, FAAP, a practicing pediatrician and assistant clinical professor of pediatrics at Harvard University School of Medicine.
 
Report 12011 with 873.42 (Other open wound of head, face, without mention of complication; forehead). For the neurological exam, report 99211-99215 and append modifier -25 with the same diagnosis; if the pediatrician determines that a concussion occurred, link 850.0 (Concussion; with no loss of consciousness) to the E/M code.

6. Use 99058 for Emergency Repairs

When the pediatrician sees a patient in the office for an emergency repair, report 99058 (Office services provided on an emergency basis) in addition to an office visit E/M code. Basically, if a physician interrupts office flow to care for a patient with a laceration, you would report 99058, Rappo says. You would not use 99058 if the physician has urgent-care appointments available as part of the regular office schedule, Linzer adds.