Wiki extensive cleaning

[JYSPA]

How do I code one layer laceration repair with extensive cleaning. The physician only states extensive cleaning with jet lavage and does not mention any contamination etc. Do I use the simple repair or intermediate?

Jyspa

 

[sjs-aapc]

Because the physician documents "extensive cleaning," I would code Intermediate repair per Repair (Closure) guidelines on page 70 of the CPT Level I code book. However, to accurately code this procedure, you will need the measurement of the repair.

 

[OCD_coder]

Be careful about giving credit for an "extensive" lavage. This is "typical" work to prevent infection, all wounds receive an lavage prior to closure. And what is extensive to one auditor may be not extensive to another. At the very least, If there is no particulate matter documented found in the wound, or fine organic matter in the documentation you will have a very difficult time supporting an Intermediate closure CPT code.

Stating "extensive" cleaning is not enough to support an Intermediate repair. The guidelines talk about removing foreign material, so if you are not removing something/anything it would not qualify.

Just some tips to help, this is what I have experienced doing ED coding and auditing.

 

[JYSPA]

Thanks. I was using intermediate but looks like it should be simple.

jyspa