Here is some information from Encoder Pro (Optum) - recommend to also include the length of repair for optimal coding:
| typical patient: A patient requires intermediate repair of wound(s) of the neck, hands, feet and/or external genitalia that have a total length of 1.5 cm. |
| pre service info: Explain procedure to patient/family. Review risks and complications. Obtain consent. Verify that all required instruments and supplies are available. Assist with appropriate positioning to expose and stabilize operative site(s) (eg, supine, prone, lateral). (Repositioning may be necessary for multiple wounds.) Prep and drape site(s). Local anesthetic is administered. Scrub and gown. Perform ""time out."" |
| intra service info: After thorough irrigation of the wound(s), a multi-layer closure is accomplished, including one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal). |
| post service info: Apply appropriate ointment and sterile dressing(s). Write orders for antibiotic and pain medication, as appropriate. Discuss aftercare treatment, including home restrictions (ie, activity, bathing). Dictate operative report and complete medical record documentation. The patient will be examined within a few days for wound check and through the 10-day global period as necessary. Discuss progress with PCP (verbal and written). Dictate progress notes for medical record. |
Lay Description:
The
physician performs a
repair of a
wound located on the neck, hands, feet, and/or
external genitalia. A local anesthetic is injected around the
laceration, and the
wound is cleansed, explored, and often irrigated with a saline solution. Due to deeper or more
complex lacerations, deep
subcutaneous or layered suturing techniques are required. The
physician closes
tissue layers under the
skin with dissolvable sutures before suturing the skin. Extensive cleaning or
removal of foreign matter from a heavily
contaminated wound that is closed with a single layer may also be reported as an intermediate repair. With multiple wounds of the same
complexity and in the same anatomical area, the length of all wounds sutured is summed and reported as one total length. Report
12041 for a total length of 2.5 cm or less;
12042 for 2.6 cm to 7.5 cm;
12044 for 7.6 cm to
12.5 cm;
12045 for
12.6 cm to
20 cm;
12046 for
20.1 cm to
30 cm; and
12047 if the total length is greater than
30 cm
