Internal Medicine Coding Alert

Published on Tue Feb 26, 2008 PDF

Question: An established patient who had an accident during a bicycle race reports to the internist with a laceration on her left knee. The physician examines the patient, cleans the wound and closes it using butterfly bandages. Can we report a laceration repair code for this encounter?

Montana Subscriber

Answer: If the wound does not require stitches, staples or tissue adhesive (such as Dermabond), you should not report a laceration repair code. CPT requires you to use one of these closure methods in order to report 12001-12007 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet] ...).

Solution: Roll the work the physician performs closing the laceration into the overall E/M level for the visit. So if notes indicate a level-two E/M, report the following:

• 99212 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: a problem-focused history; a problem- focused examination; and straightforward medical decision-making) for the E/M.

• 891.0 (Open wound of knee, leg [except thigh], and ankle]; without mention of complication) linked to 99212 to represent the laceration

• E826.1 (Pedal cycle accident; pedal cyclist) linked to 99212 to represent the cause of the laceration.