Primary Care Coding Alert

Hint: Check CCI when reporting multiple wounds of same class.

When your clinician performs a laceration repair, you will have to base your code selection on the type of repair, the anatomical location of the wound, and the length of laceration repair.

Use these three steps to help you guide your code selection whenever your clinician performs laceration repair(s) for a patient.

Step 1: Discern Between the Three Laceration Code Types

Whenever your FP performs a repair of a laceration(s), the first step to reporting the right code for the procedure would be to understand if the repair was “simple (12001-12021),” “intermediate (12031-12057),” or “complex (13100-13160).” You can check this from the patient documentation by looking at the following factors:

• The depth of the wound that was repaired
• The amount of wound debridement your clinician performed
• The type of closure that your clinician performed.

“The physician needs to explain the complexity within the body of his note,” says Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC,of ACE Med Group in Pittsburgh, Pa. “The skin, the depth, the structure of the laceration, the closure, etc. all need to be explained in detail so as to arrive at the most appropriate code.”

“Type of closure refers to whether the closure was layered or not; it does not depend on what was used in the closure. Whether a wound was closed using sutures, staples, or tissue adhesives, either alone in combination with each other is immaterial,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “The exception is wound closure using only adhesive strips. Per CPT^®, wound closure using only adhesive strips should be coded using an appropriate E/M code, not a laceration repair code,” adds Moore.

Simple repair: When the wound is superficial (e.g. primarily involving the dermis and epidermis), you will have to choose simple repair codes for the laceration repair procedure that your clinician performed. You can also choose simple repair codes for lacerations that involve subcutaneous tissues without significant involvement of deeper layers.

You choose simple repair codes when your clinician does not perform any extensive wound debridement during the procedure. Typically, when patient documentation shows that your clinician performed a one layer closure of the laceration (e.g. with simple sutures), you will have to report a simple repair code.

Intermediate repair: When the depth of the wound extends to the subcutaneous layers and to the underlying (non-muscle) fascia, you will generally have to report repair of such wounds with intermediate repair codes. You can also report intermediate repair codes when your clinician spent a lot of time in performing extensive debridement of the wound. So, even if the wound depth was superficial and the closure was single-layered, if your clinician performed extensive debridement, you can report intermediate repair codes.

When patient documentation mentions that your clinician performed a layered closure of the wound, you will have to look towards intermediate repair codes. Even if the wound extends only to the subcutaneous layers, you still choose intermediate repair codes if your clinician performed a layered closure.

Complex repair: For choosing complex repair codes, you will have to consider more than depth of the wound and layers of repair. You choose to report this set of codes when your clinician performs more than layered closure, such as scar revision, extensive tissue debridement, or even creating a defect to rectify a problem. If your clinician is performing a complex repair, it will be extremely time-consuming as the wound closure will need a lot of preparation with undermining, retention, and debridement of large skin areas.

Complex repair often involves extensive undermining, stenting, or retention sutures. In performing this type of repair, your clinician will generally use a layered closure.

Step 2: Check Anatomical Location of the Wound

Once you have discerned the type of repair your clinician performed, the next step in identifying the right laceration code that you will report for the procedure will be to identify the exact anatomical site where the wound is.

For each of the laceration repair types, you have different groups of codes depending on the anatomical location. Simple repair codes are grouped together that include the following sites:

• Scalp, neck, axillae, external genitalia, trunk and/or extremities
• Face, ears, eyelids, nose, lips and/or mucous membranes.

Similarly, intermediate repair codes are grouped using the following anatomical locations:

1. Scalp, axillae, trunk and/ or extremities (excluding hands and feet)
2. Neck, hands, feet and/ or external genitalia
3. Face, ears, eyelids, nose, lips and/ or mucous membranes.

When reporting complex repair codes, heed to these anatomical location groups:

• Trunk
• Scalp, arms, and/ or legs
• Forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet
• Eyelids, nose, ears and/or lips.

“It’s important to pay attention to the fact that the anatomical groupings differ from one class of repair to another. For instance, while scalp and neck are grouped together for simple repairs, they are in separate groups for intermediate and complex repairs,” Moore says.

When multiple wounds of the same class (simple, intermediate, or complex) are located in different anatomical sites that are grouped together, you will report the laceration repair with one single CPT^® code based on the total length of the repairs, as discussed below. “The lengths of wounds in one area (per code descriptors) are added together as per the introductory notes in CPT^®. If there are wounds in other areas, you don’t add them together,” Hauptman adds.When your clinician is performing multiple laceration repairs in anatomical sites that aren’t grouped together, you can report them with their respective CPT^® codes. In such a case, you will need to check if there are any Correct Coding Initiative (CCI) edits that bundle the codes together.

You will run into edit bundles when reporting repair codes involving same class and same length of repair but occurring in different anatomical areas. These code bundles carry the modifier indicator ‘1,’ which means that you can unbundle the codes by using a suitable modifier such as 59 (Distinct procedural service) to the code that is mentioned in the column 2 of the CCI edits. For instance, code 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less) is a column 2 code to 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). Thus, if you report both codes for the same patient on the same date of service, you will need to append a modifier, such as modifier 59, to 12011 to get it paid separately if the payer is following CCI edits.

When multiple repairs are of different class (simple, intermediate, or complex), you just report the CPT^® codes of the wound repairs. You do not have to report any modifiers as these codes in different classes are not bundled.

Example: If your clinician is performing a simple repair of a 2 cm wound located in the scalp and an intermediate repair of another 2.5 cm wound in the scalp, you just report 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) for the simple repair and 12031 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.5 cm or less) for the intermediate repair. Since there is no CCI edit for the codes, you do not have to report any modifier.

Step 3: Add up Total Length of the Wound(s) to Report Appropriate Code

Once you have determined the type of wound repair and the anatomical location in which the wound is, you will have to look at patient documentation to check the exact length of the wound to help select the right code to report for the laceration repair that your FP performed. Each of the wound repair codes carry the “length descriptor” and you will have to choose the right code depending on the length of the laceration repair performed.

If multiple wound repairs were performed, you will have to add up the lengths of the wounds if the class and anatomical grouping of the wounds are same. If either the class or the anatomical grouping of the wounds is different, you will have to report the laceration repairs separately with their respective CPT^® codes.

Example: Your FP performed simple repairs of a 2.5 cm wound of the scalp, a 2 cm wound of the neck and a 2.7 cm wound of the face. Since scalp and neck wounds are grouped together for simple repairs, you will report 12002 (…2.6 cm to 7.5 cm) for the collective length of the wounds (2 cm + 2.5 cm). You report 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 wound repair of the face. Since 12013 is a column 2 code with 12002, you should append the modifier 59 to 12013.