Capture Two Common Integumentary Procedures in Urgent Care
From wound repair to incision and drainage, know which CPT® codes accurately report simple to complex medical procedures.
Laceration repair and abscess drainage are common in the urgent care setting. Let’s review proper medical coding and documentation for these integumentary procedures.
Patients often present to the urgent care with minor injuries, including lacerations. These injuries frequently require a separate surgical procedure.
CPT® codes for laceration repairs are divided into three categories: simple, intermediate, and complex. Each category is further divided by wound length and by anatomical location. It’s necessary to have a detailed description of the wound and the repair technique to determine the appropriate CPT® code.
Simple repairs: Wounds that require only a single layer closure of the epidermis or dermis. Deeper structures are not involved, and the wound is not contaminated. Closure is achieved by suture material or by chemical closure with tissue adhesive.
Intermediate repairs: Wounds require multi-layer subcutaneous tissue and non-muscle fascia closure, in addition to epidermis or dermis closure. Heavily contaminated wounds require extensive cleaning or particulate debris removal with single layer closure. Simple blood vessel ligations and simple exploration to evaluate blood vessels, nerves, or tendons are considered inherent to the repair, and are not separately reportable.
Complex repairs: Complex repairs require additional work beyond an intermediate repair, and typically include scar revision, undermining, or placement of stents or retention sutures. Complex repairs also may include defect creation for repair.
Use caution: A physician may describe wound repair as “complex” when in fact the documented procedure note only meets simple or intermediate repair. The physician should document clearly the technique employed.
Length and Location Matter
Documentation should specify the length of the wound repair(s), in centimeters. This information is critical for medical coding.
Laceration repair codes are grouped by anatomic locations. Note that anatomic grouping may change based on the complexity of the wounds. For example, a 1 cm finger laceration requiring a simple repair is reported with CPT® code 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. If the same wound required an intermediate repair, the grouping includes only neck, hand, feet, and/or external genitalia, as reported with CPT® code 12031 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less.
Report multiple lacerations of the same type and same anatomic location with a single repair code. Add the lengths of the lacerations together to determine the length and appropriate medical coding.
Report multiple lacerations with different complexities or different anatomic locations with separate CPT® codes.
For example, an established patient presents to urgent care after tripping into a storm door and breaking the glass. She suffered lacerations to both forearms, including 1 cm and 1.5 cm lacerations to the right arm and 1 cm, 3 cm, and 5 cm lacerations to the left arm. All require repairs.
If all of the lacerations required simple repair, add together the lengths of all the wounds and report the single CPT® code 12004 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm.
If the 3 cm and 5 cm lacerations required intermediate repair, and the remaining lacerations required simple repair, report CPT® code 12034 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm for the intermediate repairs, and CPT® code 12002 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm for the simple repairs.
If you’d like to prove your expertise or learn more about urgent care and emergency coding, consider earning your Certified Emergency Department Coder (CEDC™) credential.
Incision and Drainage
An abscess is a collection of pus from a localized skin and subcutaneous tissue infection, and may result in tissue destruction. Patients may present with a minor abscess, multiple abscesses, or complex abscesses. If skin infections develop into an abscess, the provider may have to perform an incision and drainage to treat the infection.
The treatment for abscesses varies, depending on the location and severity of the infection. For smaller abscesses, the physician may aspirate the fluid with a syringe and needle, which is accurately represented using CPT® 10160 Puncture aspiration of abscess, hematoma, bulla, or cyst.
Larger and complicated abscesses require more invasive treatments. Incision and drainage of subcutaneous tissues are reported as either “simple” or “complicated.” Simple procedures are reported using CPT® code 10060 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single. These medical procedures include a simple incision of a single abscess.
When multiple abscesses are treated, report CPT®10061 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple. This CPT® code also may apply if treatment involves local anesthesia, or for a single large abscess that requires complex treatment, including irrigation, probing to break up loculations, and packing/drain placement to promote ongoing drainage.
Additional incision and drainage codes report specific anatomic locations. For example, incision and drainage of a pilonidal abscess — which is a collection of pus that appears like a large pimple in the center of the back just above the buttocks — is reported using either CPT® code 10080 Incision and drainage of pilonidal cyst; simple or CPT® code 10081 Incision and drainage of pilonidal cyst; complicated. CPT® code 10081 requires the provider to perform marsupialization, approximation of the wounds edges, and/or primary closure. This medical procedure is not typically reported in the urgent care setting.
Assigning the appropriate code for an incision and drainage of a finger can challenge even a seasoned coder. A paronychia is a simple abscess involving the lateral aspect of the nail and is reported with CPT® code 10060 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single. An abscess involving a deeper structure, such as the fat pad of the finger, is reported using CPT® code 26010 Drainage of finger abscess; simple. CPT® code 26011 Drainage of finger abscess; complicated (eg, felon) describes a more complicated abscess or felon (an infection of the tip of the finger) that requires debridement or irrigation for treatment.
Bundled Guidelines for Surgical Procedures
CPT® lists the components of a surgical service included in the procedure, which are not to be reported separately. These include local anesthesia (including digital block), immediate postoperative care, and typical postoperative follow-up care. CPT® instructions allow the reporting of an evaluation and management (E/M) service that occurs “subsequent to the decision for surgery.”
A separate E/M service may be appropriate, in addition to the surgical procedure, only when medical necessity is met. For example, a patient presents to the urgent care clinic after a fall, complaining of knee and ankle injuries. The patient was seen at this clinic last year for bronchitis. A detailed history and exam are performed, including X-rays of the knee and ankle. A 3 cm laceration was identified, which required an intermediate repair.
The final diagnosis was knee contusion and laceration, and ankle sprain. The patient is discharged with a prescription, and follow-up planned with orthopedics.
In this case, the appropriate E/M service CPT® code may be reported with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service, in addition to the surgical procedure (e.g., 99214-25 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 detailed history; A detailed examination; Medical decision making of moderate complexity, and 12032 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm).
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