Primary Care Coding Alert

Question: When should I report an open wound code rather than a superficial injury? The September 2005 Family Practice Coding Alert linked a superficial injury diagnosis with a laceration repair. Would a family physician repair a superficial injury (such as 910-919) with sutures, staples, etc., or would repair be limited to an open wound (870-897)?


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Answer: For laceration repair, you should use an ICD-9 code from the open wound series (870-897) instead of a superficial injury code (910-919). You should classify a laceration that requires repair with sutures, staples, etc., as an open wound (870-897).

A superficial injury does not require repair. An FP can care for superficial abrasions, which motor-vehicle accidents may cause, by cleaning and bandaging the site. In this case, you would include the work in the E/M code (such as 99281-99285, Emergency department visit for the evaluation and management of a patient ...) and report a superficial injury code (910-919)

Conclusion: The scenario that you refer to in Family Practice Coding Alert's reader question, "Assign V71.4 When Patient Shows No Problem," should have recommended using an open wound code with the repair code. A better example could have stated:

After an FP repairs a motorcycle accident patient's 1.0-cm laceration of the forearm, the physician places the patient under observation care for possible head trauma. The physician wants to keep the patient in observation to see if he develops any central nervous system symptoms.

If the patient doesn't develop any problems or exhibit any signs or symptoms of head trauma, you should report the observation care code (such as 99218-99220, Initial observation care, per day, for the evaluation and management of a patient ...) with V71.4 (Observation and evaluation for suspected conditions not found; observation following other accident).

Link the simple repair code (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 the open wound diagnosis (881.00, Open wound of elbow, forearm, and wrist; without mention of complication; forearm). To indicate that a motor-vehicle accident caused the injury, you should also assign E810-E819 (Motor-vehicle traffic accidents). Use a fourth digit of "2" or "3" to identify the injured person as a motorcyclist (E81x.2) or a passenger on a motorcycle (E81x.3).