Pediatric Coding Alert

Question: A new patient presents to our office with a 2.0 cm cut on her chin from falling on the side of her bed. The wound is closing well on its own, and the physician cannot pull it apart enough to warrant using sutures. After cleaning the area, she instead uses steri strips to close the wound. Can I use 12001?

South Carolina Subscriber

Answer: No, because the wound closure uses only steri strips, you should include the work in the office visit code (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...). "Wound closure utilizing adhesive strips as the sole repair material should be coded using the appropriate E/M code," according to CPT's "Repair (Closure)" guidelines.

Consider the E/M level based on the closure's amount of time, work, and complexity. But do not also report an additional procedure code for closing the chin wound (873.44, Other open wound of head; face without mention of complication; jaw). The repair codes, including 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) require suturing or Dermabond.

Provided the documentation supports a significant, separately identifiable E/M, you could have also reported 9920x appended with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service). For instance, an E/M-25 might have involved a new patient history to check for any allergies, a problemfocused exam of the facial area and possibly for any other injuries from the fall (E888.1, Fall resulting in striking against other object), and deciding whether the wound would stay closed on its own, need steri strips, or require sutures.