Pediatric Coding Alert

For primary care providers, this service often walks the E/M-procedure line.

Spring is nigh, as are patients reporting to the pediatrician with the first few scrapes and cuts that the spring thaw typically brings. Coders need to be on point with laceration repair smarts before the kids with cuts start coming.

Help’s here: We chatted up Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash., to see what she had to say about laceration repair coding. 

Check out Bucknam’s take on coding for these services, and keep this article close in case a pediatric patient reports with a laceration.

Code Most Repairs As E/Ms or Simple Closures

Patients reporting to a pediatric practice for laceration repair will typically require some sort of superficial repair. The details of that repair will determine how you code the service.

E/M code scenario: If the provider uses adhesive strips or bandaging to close the wound, report the appropriate-level E/M code, Bucknam advises. 

For example, let’s say an established 11-year-old female patient reports to the pediatrician’s office with a new complaint of a skinned right knee. The provider examines the wound and cleans it with warm soapy water. Then, she uses gauze and sterilized bandages to close the patient’s wound. Notes indicate that the provider performed an expanded problem-focused examination and history, and low-complexity medical decision making (MDM), during the encounter. Final diagnosis is a right knee laceration without foreign body.

Since the pediatrician used only gauze and bandages to close the wound, you would report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity …) for the service with S81.011A (Laceration without foreign body, right knee, initial encounter) appended to represent the reason for the patient’s visit. 

Procedure code scenario: When your pediatrician uses other means to close a patient’s cut, the service might qualify as a simple laceration repair, which you’d report with codes from the 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) to 12018 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm) set. 

Simple laceration repairs are usually “minor wounds that require little or no cleansing or debridement, although the wound edges could be ‘freshened’ if the repair is delayed,” explains Bucknam.

Simple laceration repair codes are for use if the provider closes a cut with sutures, staples, or tissue adhesive, Bucknam reminds. “The [simple laceration repair] codes include any local or topical anesthetic,” she continues.

Break Simple Repairs Down by Anatomy

If you do decide that your provider performed a simple laceration repair, you’ll have to discover details in the claim that lead you to the length and anatomical area of the repair

Why? CPT^® cuts simple laceration repair into two categories: 

• scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet), represented by 12001 through 12007 (… over 30.0 cm) and 
• face, ears, eyelids, nose, lips and/or mucous membranes, represented by 12011 (… 2.5 cm or less) through 12018. 

Consider this example: The pediatrician closes one laceration on a patient’s forehead using sutures. The repair length is 2 cm, and notes indicate that the physician placed four sutures after minimal cleaning.

For this encounter, you’ll likely report 12011 for the wound repair with S01.81XA (Laceration without foreign body of other part of head, initial encounter) appended to represent the patient’s condition.

Check for Separate E/M on Repairs

When your provider performs a simple laceration repair, he will also perform an E/M prior to the procedure. That E/M service may or may not be separately codeable, however.

For most payers, a minor laceration repair code would likely include the work directly involved in that repair: wound prep, cleaning, topical anesthesia, etc. If there were other concerns that the provider addressed in the pre-repair E/M — such as possible underlying fracture, concussion, etc.— then you might be able to report a laceration repair code and a separate E/M code. 

Remember: You should only consider an E/M in addition to a laceration repair code if you can prove the provider performed a significant, separately identifiable E/M in addition to the repair. Also, you’ll need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to any E/M code you file in addition to the repair code, Bucknam reminds.