Tighten Up Your Laceration Repair Coding Skills

October 24th, 2022 - Aimee Wilcox
Categories:   Audits/Auditing   Coding  

Assigning the correct CPT code for laceration repairs depends on documentation of three key elements: 

  1. Complexity of the Repair: Laceration repair codes are categorized as simple, intermediate, or complex.
  2. Anatomic Site: Laceration repair codes are also categorized by the anatomic site of the laceration. For example, 12001-12007 are assigned to report lacerations of the scalp, neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet), while 12011-12018 are assigned for lacerations repairs of the face, ears, eyelids, nose, lips, and/or mucous membranes.
  3. Length of the closed wound measured in centimeters (cm): The code description of these codes includes the length in cm required to report it, for example, the following shows the length of the repair associated with the code for reporting it:

Suture Materials Help Identify Superficial Closures

While the materials used to close a wound are not part of the code description, they are required in the documentation to support any future services that may need that information (eg, suture removal). This information also helps coders quickly identify if a wound was deep or superficial as some suturing materials are absorbable and others are not. Absorbable suture materials will dissolve over time, which makes them perfect for deeper wounds, sometimes these must be used for deeper tissue repairs where the absorbable sutures simply are not going to hold long enough for the incision site or wound to heal such as is used in heart surgeries, or other vital organs including blood vessels). Non-absorbable sutures, on the other hand, will not dissolve and are used for the closing the exterior layer of skin. Non-absorbable sutures can be removed anywhere from 5 days to a few weeks, depending on wound healing and anatomic site, which also provides an opportunity for the provider to check the wound for any signs of infection or dehiscence (re-opening of the wound). 

The following are some examples of absorbable and non-absorbable suture materials: 

Absorbable Sutures

There are two types of absorbable suture materials: 

Natural: Plain or Chromic Catgut (made from twisted collagen fibers taken from the subserosal layer of intestinal tracts in certain animals)
Synthetic: Made from synthetic materials such as polyglycolic acid, polyglactin 910, poliglecaprone, and polydioxanone. These are more commonly documented as Dexon, Vicryl, Monocryl, or monofilament sutures. 
Non-absorbable Sutures:

There are several types of nonabsorbable sutures, which are used to close the outer layer of the skin and, as noted previously, sometimes certain vital organs to allow them more healing time or a longer-lasting secured closure. These include: 

Polypropylene, nylon, and polyester sutures (silk was used for a long time but many patients had allergic reactions or the suture material simply wasn’t strong enough to endure tissue movement after repair without breaking. The medical record will record the brand of suture materials such as Prolene, Ethilon, Procare, Unibond, Neobond, etc., and not the chemical name. Dermabond glue is another material used to close superficial wounds.

Coding Multiple Laceration Repairs

Multiple wounds of the same body part and complexity should have their lengths added together to determine the CPT code that should be reported. Do not add together the length of wounds when they are not located in the same anatomic site. Wounds from different sites are billed separately. To prevent claim denials based on duplicate coding, be sure to add the appropriate modifier to the second and each additional laceration repair code to indicate multiple procedures were performed. Consider modifiers 51, 59, or one of the Medicare X{ESPU}  modifiers to indicate a separate, identifiable procedure has been performed from the initial being reported. 

Formatting Encounter Notes to Capture Minor Procedures

Simple laceration repairs may be cleaned, debrided, irrigated, dried, glued or sutured but when they are small, many times providers fail to document these in a manner that they can be identified by coders, or they fail to include all of the criteria required to report the code. This is very prevalent in the Emergency Department (ED), either where the contracted ED providers want to use their own templates instead of a formatted template that helps guide documentation in the record for a more complete report. 

Nowadays, many organizations are engaged in the use of computer assisted coding (CAC) programs, which allows reports to run through an engine that has been programmed to identify section headers (e.g., Exam, MDM, Lab) as a location where either a procedure service or diagnosis may be documented. The engine is trained to look for specific diagnoses and procedure details and titles and autosuggest an appropriate code. As coders, it is hard to memorize every detail or piece of criteria required to support a given code for the tens of thousands of codes being reported, but for a programmed computer, it can be done quickly and often very precisely, reducing the time it takes for coders to identify and code a report. That does not mean coders will be replaced. What it does mean, is that more can be done in the same timeframe and coders then become auditors of the engine’s precision rates. 

Lacerations, for example should be documented beneath a formatted section header titled and include the name of the procedure and the details required to support the code. The following is a poor example of a laceration repair being documented in the middle of an E/M encounter followed by an excellent example that would allow any coder or engine to quickly identify a procedure had been performed and verify all criteria of that code have been met. 

Example 1: 

Laceration Repair performed: yes. Location of laceration: 1st laceration. 1st laceration details: first laceration detail length 1cm Repair Type: Simple wound closure. 1st Suture details: Layer skin. Suture type Vicryl rapide. Number of sutures: 2. Suture size 6-0. Method: Interrupted. Tetanus vaccine within last 5 years, procedure status completed

Example 2: 


1. Laceration repair (simple), right eyebrow, 3.5 cm in length.
2. Laceration repair (simple), scalp, 4 cm in length.

Details of the Procedure: The risks, benefits, and alternatives to the procedure were discussed with the patient and verbal consent was obtained. A time out was performed by the clinical team to verify the with patient. The laceration sites were prepared in the usual sterile fashion, a draped applied, and local anesthesia of lidocaine 1% with epinephrine was administered with good anesethesia noted. The laceration of the right eyebrow was examined and the skin edges were clean and well defined. Repair of the 3.5 cm laceration was performed using without any difficulty using nonabsorbable 5-0 nylon in an interrupted fashion with a total of 6 sutures placed. Our attention was turned to the laceration of the scalp. The wound was cleaned, irrigated, and showed poorly defined skin edges. These were repaired using 5-0 nylon in an interrupted fashion with a total of 8 sutures placed. The patient tolerated the procedure well and there were no complications. Hemostasis was achieved and the patient was neurovascularly intact.

After comparing these, can you see how much easier it is to see that a procedure was performed, what was performed, and to easily identify the three key criteria required to code the service correctly? In the first example, the anatomic site is missing, which is a key piece of information required to identify the correct code to be reported. 

Take the time to review the E/M encounters of providers that perform these services and get a better idea of how easy it is to support the minor procedures being performed. How well would the record stand up in an audit, are all criteria present? Are coders assigning the right codes based on anatomic site? And finally, consider implementing a procedure section header for easy identification of any procedures performed during the encounter. This will provide clarity, better CAC engine autosuggestion, and improved coder/auditor results.  



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