Repair of leg wound

[Rajesh Kumar J]

When the documentation in the anesthesia record states Repair of leg wound with no documentation about Simple or intermediate or Complex repair, which CPT is to be coded-either intermediate or Complex? Simple repair cannot be coded as it involves the use of local anesthesia which is non-billable. The ASA code for all the three will be 00400.Kindly clarify either intermediate or Complex repair CPT code can be coded

 

[ANDREAHSANCHEZ]

So there is no documentation of the size of the wound and there is no way to find out from the physician. Your saying there was no injection for the pain while the stiches were placed or there also is no documentation of this. just a little unclear and if none of this is documented your physician will not be getting much reimbursement, as a coder I would find these things out to get proper reimbursement or else you bill at the lowest possible wound repair for this procedure. Look at how many sutures were placed, this could be an indication on how large the wound was but without proper documintation I would be hesitant to bill.