Wiki Laceration Repair

[Stella19]

Hello,
A patient comes to the ED with a laceration of the forearm. The documentation states "No Foreign Bodies", and they perform Extensive Cleaning of the wound. Would you code this to 12001 Simple repairs of superficial wounds of scalp, neck, axillae, external genitalia, trunk and or extremities; 2.5 or less, because of no FB or would you code it to 12031 Repair, intermediate, wounds of scalp, axillae, trunk and or extremities, because of extensive cleaning?
For Intermediate repair guidelines in the CPT codebook states, Single-layer closure of heavily contaminated wounds that have required extensive cleaning OR removal of particulate matter also constitutes intermediate repair.
Thank you in advance for your help.

 

[csperoni]

If the documentation states "extensive cleaning" but then no foreign body and NO mention of what extensive cleaning meant to that provider, I would query the provider. I would want something to justify intermediate. Otherwise, I would code this as simple.

This is from supercoder for 12031:
Document extensive cleaning to up complexity
Make sure your physician documents the extent of the debridement he or she performs. Although intermediate repair usually requires layered closure, you can report appropriate intermediate codes if your physician performs a single–layer closure of heavily contaminated wounds that require extensive cleaning or removal of particulate matter, according to CPT® guidelines. But your physician may forget to include the cleaning details when recording laceration services. Therefore, you would not know that the repair qualifies for an intermediate repair code and will use a simple repair code instead.