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Thread: CPT code for Laceration Repair

  1. #1

    Default CPT code for Laceration Repair

    Hello,

    Laceration repair ( Repair of skin using electrocauterization)... Can anyone suggest the appropriate CPT code for this? Does this procedure qualify for a CPT code assignment?

    Thanks
    Asha

  2. #2

    Arrow Wound Closure

    Look at the guideline in the CPT book for wound closure. Your answer lies there. I am highlightening for you in green.

    12001-16036
    Repair is the surgical closure of a wound. The wound may be a result of injury/trauma or it may be a surgically created defect. Repairs can be any of the following:
    -Stand alone procedures
    -Separately reportable services when performed with certain other procedures as in the case of excisions requiring intermediate or complex repair
    -An integral part of a more complex procedure and not separately reportableRepairs are divided into three categories: simple, intermediate, and complex. They are further described by anatomic site and wound size.Simple repair is performed when the wound is superficial, e.g., involving partial or full-thickness damage to the skin and/or subcutaneous tissues. There is no significant involvement of deeper structures and only simple, one layer, primary suturing is required. This procedure includes local anesthetic and chemical or electrocauterization of wounds not closed.

    Wounds closed with adhesive strips should be reported using the appropriate evaluation and management code.Intermediate repair is performed for wounds and lacerations in which one or more of the deeper layers of subcutaneous tissue and non-muscle fascia are repaired in addition to the skin and subcutaneous tissue. Single-layer closure can also be coded as an intermediate repair if the wound is heavily contaminated and requires extensive cleaning or removal of particulate matter.

    Complex repair includes repair of wounds requiring more than layered closure. Wounds coded from this category include those requiring revision, debridement, extensive undermining, and placement of stents or retention sutures. Complex repairs also include those requiring creation of a defect (e.g., extending excision) and special preparation of the site.The following rules should be followed when reporting repairs:
    -Measure the length of the repaired wound or wounds and report in centimeters. A centimeter is 0.39 inches.
    -Add together the lengths of multiple wounds in the same classification and report as a single item. For example, a simple repair of a 2-centimeter scalp wound and a simple repair of a 1.5-centimeter wound of the forearm would be reported with a single code. 12002 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm This procedure is coded with a single procedure code because both wounds are classified as simple and both are in the same group of simple repairs (12001-12007). Total length of the two wounds is 3.5 centimeters so 12002 is reported.
    -Wounds in more than one classification should be listed separately with the more complicated service listed as the primary procedure and the less complicated listed as the secondary procedure with modifier 51 Multiple procedures appended.
    -Decontamination and debridement are considered integral to wound repair except when gross contamination requires prolonged cleansing or when appreciable amounts of devitalized contaminated tissue must be removed.
    -Repair of nerves, blood vessels, and tendons should be reported under the appropriate system. Repair of associated skin wounds is considered integral to the repair of nerves, blood vessels, and tendons and is not reported separately unless the wound repair qualifies as complex. In these instances report the complex repair code.
    -Simple exploration of nerves, blood vessels, and tendons exposed in an open wound is considered integral to the repair and should not be reported separately.
    -Wounds resulting from penetrating trauma that require exploration, enlargement, extension, dissection, removal of foreign body, and/or ligation or coagulation of minor blood vessels of subcutaneous tissue, muscle fascia, or muscle should be reported with 20100-20103 as indicated.

    Thank You
    Amit Joshi MSc,CPC,CPC-H

  3. #3

    Default Chemicals for simple repair

    Could you give more insight on chemicals that can be used for simple repairs? Are these special brands of supplies that qualify for it?
    Also the highlighten line in green said "anesthesia AND chemical or electrocaterication." Just want to make sure that both hve to be done in order to qualify for the procedure, right?

  4. #4

    Default ear & scaple lac repair

    I need clarification on the below senario

    Ear and scalp laceration's are 2 separate repairs and 2 separate charges. The scalp is always separate from the rest of the boby. Is this correct?


    PROGRESS AND PROCEDURES
    Laceration Repair: Location: right ear. Length: 2.5 cm. Complexity: simple (local anesthesia used and sutured).
    Wound depth/shape- subcutaneous and irregular. Wound is clean. Distal neuro/vascular/tendon status normal. Anesthesia provided by digital block using 1% lidocaine. Prepped with Betadine. Wound explored and cleansed. Closure of skin: interrupted 6-0 (5 sutures). Post-procedure: he is stable and there are no complications. Bleeding is controlled and neuro-vascular status is intact distal to the wound. Estimated blood loss: 4 mL. Tetanus immunization up-to-date.
    Laceration Repair #2: Location: scalp. Length: 0.5cm. Complexity: simple (local anesthesia used and sutured).
    Wound depth/shape- subcutaneous and linear. Wound is clean. Distal neuro/vascular/tendon status normal. Local anesthesia provided using 1% lidocaine. Prepped with Betadine. Wound explored and cleansed. Closure of skin: interrupted 5-0 (1 sutures). Post-procedure: he is stable and there are no complications. Bleeding is controlled and neuro-vascular status is intact distal to the wound. Estimated blood loss: 1. Tetanus immunization up-to-date.

  5. #5

    Default

    In the CPT look under Repair--Simple, codes 12001 to 12018 there are 2 groupings of anatomic sites as follows: (1) scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet) and (2)face, ears, eyelids, nose, lips and/or mucous membranes. If you look under Repair--Intermediate, codes 12031 to 12057 there are 3 groupings of anatomic sites and if you look under Repair--Complex, codes 13100 to 13153 there are 4 groupings of anatomic sites. In each case the scalp is part of a group of anatomic sites. Hope this clarifies your question. The correct codes for the 2 repairs would be 12011 and 12001.

  6. #6

    Question size of the repair

    It has been our understanding that the size of the wound is the initial size of the wound that the code is based on not the final size of the wound. A plan is denying all repairs because the op report didnt indicate the final length of the laceration and is claiming that because the cpt book says "repaired" wound that means the final size of the wound after it has been repaired should be documentated and not the initial. Please help!!

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