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laceration repair and size

  1. Question laceration repair and size
    Medical Coding Books
    Is there ever a time where you can code a laceration repair without the size documented? Such as if the physician just provides the CPT code. We have a physician who refuses to document the length of the laceration but will provide a CPT code.

    I do not feel comfortable coding the CPT code just because the physician provided it. His documentation must justify his CPT code and since he did not document the length then how can you code the laceration repair?? my coworkers have informed me that they have always coded a low level laceration repair if the physicians do not document the size. I do not agree. What do you think???

    the physician has all ready been given the guidelines and he still refuses. Any other suggestions on this would be appreciated. Thanks

  2. #2
    Columbia, MO
    I have never known a physician to repair a laceration and not provide the size. But I agree with you not documented is not done and we cannot guess.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    I have had physicians refuse to document items on occasion. The best method of getting their attention is attach a monetary value to it. Provide a sum of the total dollars collected over 12 months of these questionable procedures and let him/her know they are on the audit hit list. Is their lack of concern worth the fines and penalties that will be enforced for abusive claim submission???? Especially when staff have documented his/her refusal to document correctly. That usually works! We are here to keep them out of the orange jump suits!

  4. #4
    Milwaukee WI
    Default NO length defaults to shortest length
    I had several physicians who were constantly lax in documenting the length of laceration repairs. The Emergency room doctor would say "patient here with 7 in laceration of forehead/scalp - Plastics came to repair" Then the Plastic surgeon would just document HOW he repaired the laceration without giving any length. I told the surgeon I could only code the smallest length. This was really leaving money on the table.

    I did prepare a table showing the difference in charges and reimbursement for the various lengths of laceration.

    They are MUCH better about documenting this now.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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