Primary Care Coding Alert

Question: An established 17-year-old patient reports to the FP after stepping on a rusty nail. After examining the patient and making sure the wound was free of debris, the FP performs a tetanus injection and repairs the 1.2 cm hole in her left foot with sutures. Can I report a laceration repair code in this scenario?

Illinois Subscriber

Answer: Since the FP used sutures, you can submit a laceration repair code. On the claim, report the following:

" 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 repair

" 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) for the tetanus administration

" 90703 (Tetanus toxoid adsorbed, for intramuscular use) for the tetanus supply

" the appropriate level code (e.g., 99212, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making &) for the E/M

" modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M code to show that the E/M was separate from the other services

" 892.0 (Open wound of foot except toe[s] alone; without mention of complication) appended to 12001, 90703, 90471, and the E/M code to represent the patients injury

" E920.8 (Accidents caused by cutting and piercing instruments or objects; other specified cutting and piercing instruments or objects) appended to 12001, 90703, 90471, and the E/M service to represent the cause of the injury.