ED Coding and Reimbursement Alert

These 3 rules can save you $50 per cut

Reimbursement for laceration repairs could be slipping away if you're resorting to simple repair codes (12001-12021) when you could -- more accurately -- report intermediate repairs (12301-12057). Keep these three expert recommendations in mind when identifying whether you've earned intermediate repair pay.

1. Uncover Layer Descriptions

You need solid physician documentation to choose between simple (12001-12021) and intermediate (12031-12057) repair codes -- so encourage the emergency department (ED) physicians to use specific language to describe their services. You'll have an easier time selecting the appropriate code this way, says Catherine Brink, CMM, CPC, president of HealthCare Resource Management Inc. in Spring Lake, N.J.

For example, if the physician documented a 2.2-cm superficial wound on the forearm that primarily involved the epidermis, dermis or subcutaneous tissues without significant involvement of deeper structures, she probably performed a simple one-layer closure. In this case, you would report 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).

On the other hand, if your physician performs an intermediate repair, she treats wounds that include the simple repair services but also require layered closure of one or more deeper layers of subcutaneous tissue and superficial fascia, Brink says.

Hint: Look for key phrases that signal that the physician performed an intermediate repair. In the above example, the phrase "layered closure" should give away which code to choose. Other terms that may alert you to an intermediate repair include "deeper layers of subcutaneous and superficial (nonmuscular) fascia" or "deep layer suturing," so keep your eyes peeled for these cues.

2. Clean Up Complexity

Although intermediate repair usually requires layered closure, you can sometimes report intermediate codes when the ED physician performs a single-layer closure of heavily contaminated -- or "dirty" -- wounds. According to CPT, single-layer closures involving extensive "cleaning or removal of particulate matter" constitute intermediate repair, says Michael A. Granovsky, MD, CPC, FACEP, vice president of coding at MRSI in Stoneham, Mass. 

Your physician may forget to include the cleaning detail when documenting laceration services. Explain that omitting these details could easily cost the practice $50 per repair.

Example: After a skating accident, a patient presents with a 2.7-cm gash on his right knee. Because the accident occurred on a gravelly road, the cut contains a lot of gravel and debris. The ED physician spends a considerable amount of time cleaning the wound to remove the gravel before performing a single-layer repair.

If she documents "sutured 2.7-cm wound, knee" but not "extensive cleaning or removal of particulate matter," you'd have to report 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) -- even though the physician actually performed the work to earn 12032 (Layer closure of wounds of scalp, axillae, trunk, and/or extremities [excluding hands and feet]; 2.6 cm to 7.5 cm), the intermediate repair code you could have reported had the documentation included "extensive cleaning." According to the 2004 Physician Fee Schedule, the average fee for 12002 is about $78. The average fee for 12032, on the other hand, is about $147 -- a nearly $70 difference.

3. Identify Sites for Multiple Repairs

Ratchet up your coding skills: You may have mastered how to identify intermediate repairs, but you still have to learn how to categorize multiple lacerations. 

To effectively report laceration services and receive proper reimbursement, you must know how to bill all of the services the chart report contains, says Marti Geron, CPC, CMA, CM, coding and reimbursement manager at the University of Texas Southwestern in Dallas.

When the physician documents several repairs in one patient encounter, you have to identify each repair class (such as simple or intermediate) and the wound's anatomic site. To code multiple repairs, first tally the number of wounds in the same classifications. If the wounds that fall into the same classification occur in the same anatomic area, such as the knee, add the repairs together for one total.

For example, if the ED physician repairs a 3.2-cm superficial wound on a patient's right knee and a 5.4-cm simple laceration on that same knee, you should total the measurements (3.2 cm + 5.4 cm = 8.6 cm) and report one 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), Brink says.

Warning #1: Don't forget that CPT instructs you not to sum the lengths of a simple repair with that of an intermediate repair -- you need to report those repairs separately. For example, if the ED physician performs simple repairs on a 5.3-cm wound on the patient's face and a 2.8-cm wound on his nose during the same encounter, you should add the lengths and report 12015 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips, and/or mucous membranes; 7.6 cm to 12.5 cm). However, if the second wound required intermediate-level repair, you'd report 12014-59 (... 5.1 cm to 7.5 cm; Distinct procedural service) for the first wound repair and 12052 (Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm) for the wound on the nose.

Warning #2: For wounds allocated in different categories of anatomic site -- for example, one wound on the face and the other on the scalp -- you should not add the wound lengths to select the correct code. Instead, report the code for each procedure and append modifier -59 to the less complex procedure code.