ED Coding and Reimbursement Alert

Question: What is the correct code for the repair of a tongue laceration? The ED physician documentation states that a patient had a very large, gaping, deep laceration to the middle of her tongue, about 50 percent of the width of the tongue. What level of repair is this?

North Carolina Subscriber

Answer: In this case, if you provide detailed documentation, code 41252* (repair of laceration of tongue, floor of mouth, over 2.6 cm or complex). Its also likely that the patient would need conscious sedation, which is billable as 99141 (sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) or 99142 ( ... oral, rectal and/or intranasal). Billing for both procedures requires solid documentation. The laceration repair documentation must state the length and severity of the wound. For the conscious sedation, youll need to document a presedation physician assessment, conscious sedation procedure, observation by a nurse (or other trained observer), and electronic monitoring (pulse oximetry). The chart must also document that the physician administered the conscious sedation and the medication, and describe the method used in the conscious sedation procedure.

Remember, in this case, the physician who repaired the tongue also provided the conscious sedation. For more information about conscious sedation, please see Justify Use of Conscious Sedation Codes with Thorough Documentation to Get Payment in the November 2000 ED Coding Alert.