General Surgery Coding Alert

When your surgeon "explores" a wound, you may be looking at anything from a simple laceration repair to a full-on exploratory surgery, such as a laparotomy or thoracotomy. To make sense of the options, consider these expert-approved pointers.

In many cases, a code from the 20100-20103 range will be your best choice to describe wound exploration. Generally, explorations of this type occur when the patient experiences a "penetrating" trauma, such as a stab wound, gunshot, etc.

Important: "You must ask yourself, -is this a penetrating wound?- If so, the wound exploration codes may apply. Codes 20100-20103 would never apply for blunt trauma, however," advises Terri Brame, CPC, CPC-H, principal at BEST Coders.

As CPT describes, 20100-20103 can involve not only exploration but also:

- "enlargement" of the wound, including extension of dissection,

- debridement,

- removal of foreign body(s),

- ligation or coagulation of minor subcutaneous and/or muscular blood vessels, subcutaneous tissue, muscle fascia and/or muscle.

"In the CPT guidelines for these codes, exploration and enlargement of the wound is just one in a list of procedures that may be performed under 20100-20103," Brame confirms. For instance, "Removing a foreign body from a penetrating wound falls under these codes, as would cleaning up the interior edges and inspecting for foreign body fragments on a through and through (entry and exit wound)," she continues.

You should apply wound exploration codes according to the location of the wound the surgeon explores, as follows:

- 20100 -- Exploration of penetrating wound (separate procedure); neck

- 20101 -- - chest

- 20102 -- - abdomen/flank/back

- 20103 - -extremity.

What to watch for: The surgeon should document the exploration, as indicated by his assessment of the damage, including damage to vessels and non-major structures, according to the AMA's CPT Assistant, June 1996.

Example: Several small shards of metal become embedded deeply in a machine shop employee's upper leg as a result of an accident with a lathe. Using forceps, the surgeon removes the metal, looking carefully to be sure that he has removed all the foreign bodies. He then cleans and closes the wounds.

In this case, you may report 20103 for the wound exploration and foreign body removal.

If the surgeon repairs major structures or blood vessels, or if the surgeon must perform a more extensive opening via laparotomy or thoracotomy, for instance (in contrast simply to "enlarging" the wound), you would report only the specific repair code(s).

"More precisely," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians (UWP) and Children's University Medical Group (CUMG) Compliance Program, "you stop using the exploration codes when you enter a body cavity (chest, abdomen, cranium). Even if you are just -enlarging the wound,- if the enlargement enters a cavity, you use the thoracotomy or laparotomy, etc., codes."

"Wound exploration codes focus on the wound that was created traumatically, and minimal repair of that traumatic area. Anything beyond looking around, removing foreign body, and the most basic of repairs, and wound exploration is no longer appropriate," Brame verifies.

Note that the wound exploration codes are "separate procedures," "and therefore would be superseded if the subsequent procedure provided is inherently inclusive of the wound exploration code," instructs CPT Assistant, June 1996.

For instance: CPT Assistant provides an example of a young man who suffers a gunshot wound to the neck. Exploration of the wound under anesthesia revealed no damage to the carotid artery or internal jugular vein, the trachea, the recurrent laryngeal nerve, the vertebral artery or the thyroid lobe. The surgeon did discover a tangential injury to the lateral wall of the esophagus, which he debrided and repaired.

Although this service resembles a wound exploration (20100) in many respects, the injury to the lateral wall of the esophagus qualifies as repair of a major structure. Therefore, you would report 43410, (Suture of esophageal wound or injury; cervical approach). You would not report the wound exploration separately.

If the surgeon documents removal of foreign body(s) via incision, you should select the appropriate incision and removal code from the corresponding anatomical section of CPT (for example, foot [28190-28193]; shoulder [23330-23332]; eyelid [67938]; etc.).

Worth stressing: "You should apply the incision and removal of foreign body codes when a surgical incision must be made to remove the foreign body. If the surgeon doesn't make an incision, these codes probably aren't appropriate," Brame says.

Remember: You should include foreign body removal when it occurs as a part of wound exploration, confirms CPT Assistant, August 1996.

If the surgeon documents wound repair with sutures, staples or tissue adhesives, without extensive dissection or repairs, you should select from among the repair/closure codes 12001-13153. Although these procedures are not as extensive as wound exploration which 20100-20103 describe, 12001-13153 may include debridement and removal of foreign matter, as well as layered closure.

"You would use the wound repair codes when nothing on the wound exploration requirements list [in CPT] occurs. There would be only closure with limited debridement. The surgeon does not enter or digitally explore the wound," Brame says.

Remember: When reporting laceration repair, add together the lengths of all repairs in each anatomic group and select a single, "comprehensive" repair code.

Example: Your surgeon provides simple repairs for three lacerations measuring 2 cm, 3 cm and 3 cm, respectively, on the patient's forearm. In addition, the surgeon provides a 1-cm intermediate repair with some debridement, also on the forearm.

In this case, because the simple repairs all occur in the same general location (the forearm), you should add together the lengths of all the repairs (2 cm + 3 cm + 3 cm = 8 cm) to choose a single code, 12004 (Simple repair ... trunk and/or extremities ... 7.6 to 12.5 cm).

The final repair, although occurring at the same location, is of a different severity (intermediate). Therefore, you would report it separately using 12031 (Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.5 cm or less).

Look to 59: In addition, you will want to add modifier 59 (Distinct procedural service) to 12004 to specify that the superficial wounds are separate and distinct from the intermediate repair 12031. Without modifier 59, payers may bundle the simple repair to the intermediate repair of the same anatomic location.

Get the whole story: For complete information on coding laceration repairs, see "Cut to the Facts of Wound Repair," General Surgery Coding Alert, Vol. 10, No. 7, pages 49-51.