General Surgery Coding Alert

Question: The physician documented a 2.2-cm superficial wound on the forearm that primarily involved the epidermis "without significant involvement of deeper structures" and performed a one-layer closure. Should I report this repair as simple or intermediate?


Alabama Subscriber

Answer: You should report a simple repair 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) because the wound was less than 2.5 cm long, on the forearm and did not require an intermediate or complex repair. Your clue to simple repair are the phrases "superficial" and "without ... deeper structures."

If the surgeon had performed an intermediate repair, on the other hand, there are several key phrases that will give it away, such as "layered closure," "deeper layers of subcutaneous and superficial (nonmuscular) fascia," "debridement," or "deep layer suturing." Keep your eyes peeled for these cues.

Remember that CPT groups laceration repair codes by length, anatomic site and repair complexity. Also, keep in mind that an otherwise simple repair may actually be intermediate if the wound is heavily contaminated - but if this is the case, make sure the physician documents the extra work.

For example, after a skating accident, a patient presents with a 2.7-cm gash on his right knee. Because the accident occurred on a gravel road, the cut contains a lot of gravel and debris. The doctor spends a great deal 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."