ED Coding and Reimbursement Alert

First, be sure to know how to recognize what classifies as a laceration repair.

When your clinician performs a wound repair in the ED, you have a wide variety of coding choices. To select the right code, you’ll have to follow a few essential steps. But even with comprehensive guidelines in the CPT^® code book, many coders have questions about how to report these services.

Check out the following FAQs, along with expert answers about wound care coding.

What Constitutes a Wound Repair?

“Understanding the definitions of the different types of laceration repairs is critical to assigning the correct CPT^® codes,” says Jessica Miller, CPC, CPC-P, CGIC, manager of professional coding for Ciox Health in Alpharetta, Georgia.

“The CPT^® manual states that you should report laceration repair codes when a provider performs a wound closure using sutures, staples, or tissue adhesives, such as Dermabond^®, either alone, in combination with each other, or together with adhesive strips. When providers only use adhesive strips — and no other repair material — to perform the wound closure, coders should not report laceration repair codes; instead, the closures would be coded with the appropriate evaluation and management [E/M] code,” Miller notes.

What’s the Best Way to Code a Wound Repair?

Coding wound repairs is best handled using a three-step approach. “Coders should search the provider’s documentation to decide, first, whether the wound closure is simple, intermediate, or complex; second, where the provider closed the wound on the patient’s body; and, third, the total length, measured in centimeters, of the wound closure(s),” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

1) Assess Wound Complexity

First, determine the repair classification using the CPT^® wound repair guidelines. A simple repair involves a wound that goes as deep as the patient’s dermis or epidermis but no deeper than the subcutaneous tissue and “without significant involvement of deeper structures,” per CPT^®. A simple repair must also only involve a one-layer closure.

Intermediate repairs involve wounds that go much deeper into the “subcutaneous tissue and superficial (non-muscle) fascia,” according to CPT^®, and involve “extensive cleaning or removal of particulate matter.” Closure of intermediate wounds typically require layered closure, However, a single layered repair that was heavily contaminated, requiring extensive cleaning or removal of particulate matter also can justify an intermediate repair.

The classification will then lead you to code groups 12001-12021 for simple wound repair and 12031-12057 for intermediate wound repair. Many of the complex wound repairs (13100-13160) are performed by specialists, but ED providers can report this code set if the documentation reflects the complex nature of the repair. However, in most cases, ED providers are reporting simple and intermediate repair codes.

2) Choose the Correct Anatomic Code

Both simple and intermediate repair codes are then divided into two anatomic groups: the scalp, neck, axillae, external genitalia, trunk, and/or extremities including hands and feet; and the face, ears, eyelids, nose, lips, and/or mucous membranes.

3) Add the Total Repair Length(s) Per Classification, Location

Suppose a patient arrives at your ED after a fall from a swing set, and your provider repairs three wounds: a simple repair on the left arm that measures 11 cm; an intermediate repair on the left arm that measures 12 cm; and another intermediate repair on the left leg that measures 15 cm.

Following the classification, location, and add measurement formula, you arrive at one simple repair and two intermediate repairs (which you will add together) in the same location.

“You’ll report the single, simple repair of the left arm with 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], given the classification [simple], the location [arm], and length [11 cm],” says Falbo.

The other repairs are a little trickier to report. “Even though there are two separate wounds, you will report them together, as they are both classified the same [intermediate] and they are both of the same anatomic category [extremities]. Because of that, you will add the lengths of the two wounds [11 cm + 15 cm = 26 cm] to arrive at 12036 [Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cm],” says Falbo.

Pro coding tips: “Always list the most extensive procedure first, and remember to add modifier 59 [Distinct procedural service] to any other repairs,” says Falbo. This leaves you with a final coding for this encounter of 12036 with 12004-59.

When Do I Use a Wound Dehiscence Code?

You may also be called on to use two other wound repair codes: 12020 (Treatment of superficial wound dehiscence; simple closure) and 12021 (Treatment of superficial wound dehiscence; with packing). “You would use these codes when a provider opens up a previously sutured area that has become infected, cleans the wound, and then closes it with a simple closure [12020],” explains Miller. If the wound is really infected, the provider may decide to pack it with gauze strips (12021), leaving the wound open to allow infection to drain.