Primary Care Coding Alert

Don’t forget to check CCI for multiple laceration repair reporting.

When reporting laceration coding, you’ll have to discern between when to report simple or intermediate repair codes. In addition, you’ll have to base your selection on the anatomical area involved and the size of the laceration.

Look for Clues to Select Right Code

When your FP performs repair of any lacerations, you will have to check your clinician’s chart notes to see if you will have to report a simple (12001-12021) or an intermediate repair code (12031-12057). 

If the laceration repair involved only epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures, and it requires simple one layer closure, it is most likely you will have to report a simple repair code depending on the anatomical area and the length of the laceration. “As noted below, an exception to this single-layer rule of thumb is single-layer closure of heavily contaminated wounds that required extensive cleaning or removal of particulate matter,” observes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “In that situation, the repair may be considered ‘intermediate,’ even though it only involved single-layer closure.”

Suppose your clinician performed a laceration repair that involved deeper layers of subcutaneous tissue andsuperficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) and then your FP performed multilayered closure. In this case, you will have to report from the intermediate repair code range, again depending on the length of the laceration and the area in which the laceration occurred.

Documentation: Ask your FP to include in-depth details of the laceration that he closed in the chart notes, so it will help you zero in on the right code for the procedure. Provide adequate documentation to support the code that you have claimed. Include details of number of layers closed, the length of the laceration, and the anatomic areas involved, so you will justify the code that you are reporting for the procedure.

Look For Extensive Debridement to Report Higher Level Codes

Although you might find it straightforward to report single layered closure of superficial wounds with simple repair codes, it is not always so. If the laceration repair involved extensive and time consuming debridement, then you can use intermediate repair codes although your clinician only performed single layered closure.

When appropriate, ensure that your clinician mentions extensive debridement in his chart notes, so that you can identify this and adjust your coding level accordingly. Don’t miss out on opportunities when you can claim for a more extensive code, as you will lose out on much deserved reimbursement otherwise.

Example: Your FP performs laceration repair for an 18-year-old male patient for a cut that he received from broken glass. The laceration was 4.5 cm long and present on the right thigh area. Since there was glass shards interspersed in the wound, your FP had to spend a lot of time in removing all the pieces of embedded glass. After the debridement, the FP closed the wound with a single layer of sutures. If your FP didn’t mention the extensive debridement that he performed, you’d be prompted to 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). But in this case, you can report 12032 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 cm to 7.5 cm).

Reimbursement tip: If you look at the above example, the CPT® code 12002 has 3.06 non-facility total relative value units (RVUs), meaning that will fetch you reimbursement of $109.62 when calculated using the 2014 conversion factor of $35.8228. On the other hand, the code 12032 has 8.41 RVUs that will pay out $301.27, which means that you will lose out on approximately $192 if you fail to identify the extensive debridement factor.

Combine Laceration Repair in Same Anatomical Area

Your FP might sometimes perform repair of multiple lacerations in different anatomical areas that are covered under the same CPT® codes for laceration repair. In such a case, add up the length to report one code rather than multiple codes for each laceration repair.

When you combine several repairs, you must base them on repair class, such as simple or intermediate, and the anatomic site. To report several repairs, first tally the number of wounds in the same classification. If the wounds occur in the same anatomic sites that are grouped together into the same code descriptor, such as the scalp and the trunk, and your physician assigns them the same repair class, such as simple, add the repairs together for one total.

Pay attention to CPT® body groupings, because these may change according to a repair’s class. For instance, CPT® includes hands, feet and/or extremities in the same anatomic site for simple repairs. However, you should note that intermediate repair codes for extremities exclude hands and feet.

Example: Your FP repairs a 4.5 cm superficial wound on a patient’s scalp and a 5.9 cm simple laceration on the patient’s hand. Since the wound repair is in the same class (i.e. simple) and in the same anatomic site grouping for simple repairs, you should total up the measurements (4.5 cm + 5.9 cm = 10.4 cm) and report one code: 12004 (... 7.6 cm to 12.5 cm). But if the repairs were intermediate, you would have to report two codes as CPT® assigns the scalp and hands to different anatomical site grouping for under intermediate repairs. In such a case, you would be reporting 12032 for the scalp repair and 12042 for the repair on the hand.

“Likewise, if one repair is simple and another repair is intermediate, you cannot add them together and report a single code, even if they are in the exact same anatomical site,” Moore notes. “Instead, CPT® advises you to list the more complicated as the primary procedure and the less complicated as the secondary procedure, using modifier 59.” 

Watch CCI For Similar Repair in Different Anatomical Areas

When your FP performs repair of multiple lacerations in different anatomical areas that are covered under the different CPT® codes for laceration repair, you’ll report separate codes for each of the repairs.

To report multiple repairs of the same class, you’ll resort to multiple codes when each of the anatomical sites is covered by a different CPT® code group. But when doing so, you’ll have to check if there are any Correct Coding Initiative (CCI) edits that bundle the codes together.

These edit bundles are usually found to repair codes involving same class and same length of repair but occurring in different anatomical areas. These code bundles carry the modifier indicator of ‘1,’ which means that you can unbundle the codes by using a suitable modifier such as 59 (Distinct procedural service) appended to the code that is mentioned in the column 2 of the CCI edits. 

For example, if you are trying to report two simple repair codes such as 12005 and 12016 for repair of lacerations to the scalp and the face, respectively, you’ll face bundling. But you can unbundle the codes by appending the modifier 59 to the code 12016, because 12016 is the column 2 code in the edits.