Pediatric Coding Alert

Remember, multiple repairs might not mean multiple codes.

Patients that report to the pediatrician for laceration repair services often produce a pretty simple claim; the provider identifies a laceration, treats it and you select a procedure code or an evaluation and management (E/M) code, depending on encounter specifics.

The rub: What happens when one of your providers performs multiple laceration repairs? The answer depends on the situation, so coders that don’t know all the multiple laceration repair answers are in for a treat. Things only get more complicated when you need to involve modifiers, which might happen often depending on your payer pool.

If you’re worried, don’t be. To get the lowdown on how to code multiple laceration repairs of all types, we chatted with Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash.

Here’s what she had to say:

When Cuts Have This in Common, Add Repair Lengths Together

You should report a single code for multiple lacerations requiring the same complexity of repair on body areas that are in the same CPT^® code group, Bucknam explains.

Do this: Add the repair lengths together and report the multiple lacerations “as though they are the same single laceration,” explains Bucknam. “This includes the ‘branches’ of a stellate wound that requires closure in multiple different lines — you would measure and add together each stellate ‘arm.’”

Example: A patient reports to the pediatrician with three simple lacerations: a 3-cm cut on his scalp; a 1 cm cut at the base of his neck; and a 2.1 cm cut on the back of his neck. For this encounter, you would 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) for all three laceration repairs.

(Maybe) Make Modifier Your Friend When Cuts Differ

When a patient suffers from multiple lacerations requiring different repair complexity, or that are in body areas that CPT^® doesn’t group together, you should report the codes separately.

Example: A patient reports to the pediatrician with three lacerations: an intermediate 3 cm cut on his left ear; a simple 5 cm cut on the left side of his face; and an intermediate 2 cm cut on his right hand. The pediatrician closes all the wounds using sutures and without complications.

For this claim, you would report:

• 12052 (Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm) for the ear repair
• 12013 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm) for the face repair
• 12041 (Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less) for the hand repair
• Modifier 59 (Distinct procedural service) appended to 12013 and 12041 to represent the distinctly separate nature of the repairs — if the payer requires it.

Modifier alert: As mentioned in the above example, rules vary on modifier 59 for these encounters. When you are submitting claims with multiple laceration repair codes, “many payers want modifier 59 [Distinct procedural service] added to indicate that there were separate wounds that should not be added together,” Bucknam explains. “Although that might seem redundant since the codes would indicate different location or different complexity of repair.”

Redundancy debate aside, rules are rules — and you’ll want to know each of your payers’ policies on modifier 59 and multiple laceration repair codes. If you don’t sort it out pre-claim, you could lose money.

“Less complex repairs bundle into more complex repairs so modifier 59 can become key for appropriate reimbursement” if the payer requires it, Bucknam explains.