Wiki Laceration Repair


True Blue
Overland Park, KS
Best answers
Emergency Medicine is not my specialty, but a question was posed to me by another individual that I need guidance on , please.

The patient presented to the ER with a laceration to their hand. The provider stapled the wound, but the wound did not close properly, so the staples were removed and then nylon sutures were placed.

How would this be coded? Would you code for each repair with a modifier? Would you code for only one repair? If so, would this change the type of repair (i.e., simple to intermediate)? Would the first repair just be inclusive of the E/M level and possibly increase the complexity?


My leaning on this one would be to code and bill only for the suturing and not the unsuccessful stapling. That is more a matter of practice policy then coding rules, but probably the right approach. Suturing a wound that was stapled unsuccessfully would not qualify as an Intermediate Repair. And an E&M can be coded with 25 if the documentation supports it.

As Jim said closing that failed by the technique will not in itself allow a intermediate repair. This situation would allow for simple repair based on location and length of repair.