Results 1 to 5 of 5

Documentation required for laceration repair

  1. Question Documentation required for laceration repair
    Exam Training Packages
    Can anyone tell me what is required documentation for a laceration repair? I know a site and lengthe are required, but do they need to state how the repair was done? ie. sutures, dermabond, etc? I thought I read somewhere this was needed but now I can't find it.

  2. Default
    Yes you have to know. If they closed with steri-strips it is included in the E&M.

  3. Default
    Thanks, I know that steri-stips are in an E/M, but I need to show the doctors proof that they have to document the type of closure. Can you tell me where it specifically states this. I have looked in the CPT, but it does not say what documentation is needed.

  4. #4
    Location
    Phoenix, AZ
    Posts
    620
    Default
    Docs always amaze me. Tracey, try showing them the definition of each level of repair. Since we can only code what is documented, show them what we are looking for.
    Cyndi Allen, CPC, CIRCC
    2015 Local Chapter President, Casa Grande, AZ

  5. Default
    Quote Originally Posted by tracey66 View Post
    Thanks, I know that steri-stips are in an E/M, but I need to show the doctors proof that they have to document the type of closure. Can you tell me where it specifically states this. I have looked in the CPT, but it does not say what documentation is needed.
    I do not know of any "concrete" literature that states you have to state if you use sutures, dermabond, etc. However, I would show them the beginning of the repairs section where it states the simple repair, intermediate (layered) and complex repairs. Explain to them that if they do not take the few seconds to write down or dictate how they closed the wound and with what, they are throwing their own revenue down the drain. For instance, they could be doing an intermediate closure, but do not document and all you can do is give a simple repair and there you go... $$$ down the toilet for something that they did do but were "too busy" to write it down or dictate it. Honestly I will never understand doctors sometimes. Either it is written down or it is not done... as simple as that. I get your frustration... been there, done that. At the very, very least they need to state if it was sutures, steri-strips, dermabond, etc so you know for sure how to even code it. I do know most of the time in the disposition/plan they say suture removal in 10 days or dermabond/steri strip will fall off on its own, etc. That at least lets you know what "material" was used for the closure but they still need to be more specific about what was done especially if debriding or if the wound was contaminated, ect. I know not a lot of help, but I tried

Similar Threads

  1. Complex laceration repair and Tendon repair
    By Cheryl O in forum Medical Coding General Discussion
    Replies: 3
    Last Post: 06-08-2013, 02:11 PM
  2. Laceration Repair Documentation
    By aprilsue in forum Dermatology
    Replies: 0
    Last Post: 10-23-2012, 01:26 PM
  3. laceration repair with nerve repair
    By Tianne in forum Plastic Surgery
    Replies: 0
    Last Post: 10-11-2012, 01:54 PM
  4. required documentation?
    By PLAIDMAN in forum Compliance General Discussion
    Replies: 3
    Last Post: 06-19-2011, 03:12 PM
  5. Open wound/laceration repair with a tendon repair
    By twosmek in forum Orthopaedics
    Replies: 1
    Last Post: 04-19-2011, 01:35 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.