Wiki Complex Repair?

[ggeeorge]

A Patient presented with a head laceration resulting from a fall...

Head was cleaned with soap and water- wound was examined - no active bleeding. Small laceration measuring approx 1 cm was noted. Area was cleansed and 2% lidocaine without epinephrine was injected. Using sterile technique, an 18 gauge needle was injected into the hematoma and 7 cc of nonclotted blood was removed. As the site was draining blood, a small amount of pressure was applied and more blood was removed. A clot was seen at the opening so a decision was made to extend the laceration. A small clot was removed. Using 3.0 proline 3 interrupted sutures were placed. These will be removed in 7 days.Attempted to place a pressure dressing on wound- very difficult due to location.

Would this be a complex repair given the hematoma drainage and enlargement of the wound?
Or is this two separate codes - the repair and the drainage ?
Or, is this really just one intermediate repair?

I'm confused!
Thanks for any assistance!

 

[ellzeycoding]

No this is just a simple repair with a hematoma drained as part of the wound clean-up process.

Complex repair involves multiple layers and extensive undermining of the wound. Not done here according to the notes.

Intermediate repair also involves layered closure. Not mentioned here in the notes

Lacerations are usually repaired with simple repair codes (12XXX series of CPT).

Draining of the hematoma was just part of the wound prep and clean-up prior to the repair.

Unfortunately, the simple, intermediate, and complex repair codes are bundled according to the NCCI edits with 10140 and they cannot be billed together.