Primary Care Coding Alert

Question: Our FP recently performed laceration repair on a patient. The laceration was on the scalp. We reported 12001 for the procedure performed. The patient returned on day two with bleeding from the wound. Upon examination, our FP found that the wound was open and repeated the laceration repair. What is the global period for laceration repair? Can I report this second laceration repair using a separate CPT® code in addition to repair code reported for the first procedure? If so, should a modifier such as 76 or 78 be added to the second laceration repair code?

Missouri Subscriber

Answer: If you have reported 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 first laceration repair, then you have to report the same CPT® code for the second repair procedure that your FP performed.

You are allowed to report a second unit of the code for the procedure performed on the second day because this laceration repair code has zero global days. This means that any procedure performed on the succeeding days of the first procedure can be claimed for separately.

Since the procedure code has a zero day global period, you do not have to append a modifier such as 76 (Repeat procedure or service by same physician or other qualified health care professional)or 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period)to the second unit of 12001 that you are reporting for the laceration repair performed on the second day.

Consider assigning V58.31 (Encounter for change or removal of surgical wound dressing) to the second unit of 12001 to reflect that the service was intended to address a problem with the original dressing and sutures rather than initial treatment of a laceration.