Wiki Confusion on Laceration Documentation

[Mama3beartn]

Hello,
I just want verification on laceration repair documentation. Our providers are not always documenting the size of the laceration in the actual laceration repair description. We get alot of these below:

?After cleansing with betadine, repaired single-layer scalp wound with 14 4-0 prolene sutures under local anesthesia. No foreign material removed; no repair of underlying structures or tissue management required. Patient tolerated the procedure well and was given wound care instructions.

The size is on the progress note just in the exam under the skin or in the HPI. Are we still able to code a laceration repair if this is how it was documented with the size in those places or not?

Someone told me that the reason we can't is because the E/M and procedure are considered two separate office encounters that is why we have to bill with the modifier 25. But isn't it all still part of the pt's chart and should be able to still code the laceration repair if the size is documented or does it absolutley have to be in the repair description?

Just really confused on the whole thing.


Thank You so much

 

[jdibble]

I would not count it from the office note. All documentation must stand alone, so the procedure note should contain all the information needed to assign the correct code including the length of the repair. If I have a note that does not contain the length (or the layers repaired, etc.) I would code the repair to the lowest code for the procedure - so in this case I would code 12001 for the scalp repair. You also need to educate your doctor to make sure that all of this information is documented separately in the body of the procedure note.

 

[CatchTheWind]

I am addressing just your comment that "the E/M and procedure are considered two separate office encounters [which] is why we have to bill with the modifier 25."

You are not permitted to bill for the office visit if it was just to evaluate and make management decisions on the laceration. You can only bill an office visit on the same day as a procedure (and add modifier 25) if you provided an E/M service for something that was unrelated to the problem for which the procedure was performed, or if you did something above and beyond what is normally included in the work of the procedure (which is rare, since the "work" of the procedure includes most pre- and post-operative services).

 

[jdibble]

I am addressing just your comment that "the E/M and procedure are considered two separate office encounters [which] is why we have to bill with the modifier 25."

You are not permitted to bill for the office visit if it was just to evaluate and make management decisions on the laceration. You can only bill an office visit on the same day as a procedure (and add modifier 25) if you provided an E/M service for something that was unrelated to the problem for which the procedure was performed, or if you did something above and beyond what is normally included in the work of the procedure (which is rare, since the "work" of the procedure includes most pre- and post-operative services).

Thanks for adding that information - and I do agree with that! I had meant to mention something about that comment too, but got side tracked and hit the submit button before I did!