Laceration Repair CPT Codes and Billing Guidelines

by | Published on Mar 15, 2018 | Resources, Medical Coding News (A) | 0 comments

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About 6 million patients seek laceration treatment in emergency departments every year, according to a 2017 American Family Physician report. Primary care physicians also provide urgent laceration treatment. The goal of laceration treatment is to repair a wound safely without increasing risk of infection and with optimal cosmetic results. Reporting wound repair can be complex as the codes for these procedures are based on different aspects such as the anatomic site, depth of the wound and the size of the repair, as well as the classification of laceration repair codes and associated CPT guidelines. Medical coding outsourcing to a company with skilled coders can help physicians receive maximum reimbursement for services provided through proper coding.

Physicians repair different types of skin or tissue wounds such as abrasions, lacerations, amputations, incisions, punctures and avulsions. Wounds could be limited to one of these types of be a combination of them.

A laceration refers to an injury that causes a skin tear. Also referred to as a ragged wound, it may be caused by a blunt object or machinery accidents. The nature of the laceration depend on characteristics such as angle, force, depth, or object and some wounds can be serious, reaching as far as deep tissue and leading to serious bleeding.

CPT Classification of Laceration Repair Codes

According to CPT guidelines, laceration repair codes should be reported when a provider performs a wound closure using sutures, staples, or tissue adhesives (e.g., Dermabond®) either alone, in combination with each other, or together with adhesive strips. Further, as per CPT, the repaired wound(s) should be measured and documented in centimeters, regardless of whether the repair is curved, angular, or stellate (star-shaped). The CPT Manual classifies laceration repair codes according to three types of repair: simple, intermediate, and complex:

  • Simple repair (CPT codes 12001 – 12021) : A simple wound repair code is used when the wound is superficial, primarily involving epidermis, dermis, or subcutaneous tissues without significant involvement of deeper structures where only one layer of closure is necessary using sutures, staples, tissue adhesive, or other closure materials. Simple repair can be billed for chemical and electrocauterization of wounds not closed and include local anesthesia.
  • Intermediate repair (CPT codes 12031 – 12057) : An intermediate wound repair code includes the repair of a wound that, in addition to the requirements for simple repair, involves a layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia in addition to the skin (epidermal and dermal) closure. The single-layer closure of a heavily contaminated wound that requires extensive cleaning or removal of particulate matter also may also be considered an intermediate repair. Thus, an intermediate repair may be coded if the physician performed a layered closure or a single-layered closure that required extensive debridement.
  • Complex repair (CPT codes 13100 – 13160) : This includes repairs that require more than layered closure, such as scar revision, debridement of traumatic lacerations or avulsions, extensive undermining, stents, or retention sutures. It may also include excision of a scar requiring a complex repair or debridement and repair of complicated lacerations or avulsions.

Laceration Repair CPT Code Sets

The code sets for laceration repair are:

  • 12001-12007: simple repair to scalp, neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet)
  • G0168: wound closure using tissue adhesive only when the claim is being billed to Medicare
  • 12011-12018: simple repair to face, ears, eyelids, nose, lips, and/or mucous membranes
  • 12031-12037: intermediate repairs to scalp, axillae, trunk and/or extremities (excluding hands and feet)
  • 12041-12047: intermediate repair to neck, hands, feet and/or external genitalia
  • 12051-12057: intermediate repair to face, ears, eyelids, nose, lips and/or mucous membranes
  • 13100-13102: complex repair to the trunk
  • 13120-13122: complex repair to scalp, arms, and/or legs
  • 13131-13133: complex repair to forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet
  • 13151-13153: complex repair to eyelids, nose, ears, and/or lips

Each of the codes in the simple, intermediary and complex laceration repair code sets is classified by length of repair. For instance:

  • 12001: 2.5 cm or less
  • 12002: 2.6cm to 7.5cm
  • 12004: 7.6cm t 12.5cm
  • 12005: 12.6cm to 20.0cm
  • 12006: 20.1cm to 30.0cm
  • 12007: over 30.0cm

Tips to Code Correctly for Laceration Repairs

  • Assigning the CPT code for laceration repair depends on three things:
    • The complexity of the repair (simple, intermediate, or complex)
    • The anatomic location of the wounds closed: simple and intermediate category codes depend on location of the injury. For instance, 12001–12007 refer to simple repairs on the scalp, neck, axillae, external genitalia, trunk, and/or extremities. Codes 12051–12057 indicate intermediate repairs of wounds to the face, ears, eyelids, nose, lips, and/or mucous membranes.
    • The length of the wound closed (in centimeters): For example, code 12001 should be assigned for a repair involving any of the relevant anatomical locations that are 2.5 cm or less, while code 12002 should be used for repairs that are 2.6 cm to 7.5 cm.
  • All the wounds repaired should be coded. If the patient had multiple lacerations of the same repair complexity on the same body part, the lengths of each wound should be added together to determine the code. A Medical Economics report provides the following example: a 5-cm cut the left ankle and a 9-cm cut on the left calf would add up to 14 cm; code 12005 (12.6 cm to 20.0 cm) should be reported for a simple repair and code 12035 for an intermediate repair. Only repair lengths within a site can be added up. Lengths from different anatomic sites should be billed individually.
  • When more than one classification of wounds is repaired, the more complicated procedure must be always listed first. Modifier 51 should be added to the secondary procedure to indicate that multiple procedures were performed.
  • The repair of a superficial wound that does not require sutures but is closed with adhesive strips is included in the fee for the evaluation and management (E/M) visit and should not be billed separately.
  • If the physician performed a deep layered closure on the patient’s wound using staples for the method of repair, an intermediate repair code from the surgery section can be used. If the physician performed a single-layered closure only but had to perform extensive debridement in addition to the single-layered closure, therefore going above and beyond normal debridement, the intermediate repair code can be billed.
  • A layered closure constitutes an intermediate repair and the intermediate repair code should be billed even if the physician does not specifically use the word “intermediate” in the documentation.
  • A complex repair code is used to bill the most complicated surgical repair that a physician will perform on the integumentary system, though complex repair excludes excision of benign or malignant lesions. Complex repair is billed when the physician performs more than layered closure. Additionally, if a benign lesion was removed before the wound repair procedure, a minimum of two surgical codes can be billed: one for the removal and one for the repair.
  • The American Medical Association provides the following guidance on suture removal: removal of sutures by the physician who originally placed them is not separately reportable, since the removal is included in the initial laceration repair code. On the other hand, if the physician who removed the sutures did not place the sutures, then the suture removal would be considered part of evaluation and management (E/M) and the E/M code can be billed.
  • Debridement is not considered as a separate procedure and is usually treated as part of the repair procedure. However, debridement can be billed if the physician performs debridement on a day other than the wound closure procedure.

Physician Documentation is Critical for Accurate Coding

Medical coding outsourcing is practical option to negotiate the maze of laceration repair codes and guidelines. Experienced medical billing and coding service providers will ensure accurate coding for laceration repairs by considering complexity, location and subcategory, size and whether multiple repairs were performed. Comprehensive physician documentation is vital to determine the complexity and size of the repair(s). As there is considerable difference between the payment for the various repair types, lack of proper documentation can affect coding precision and the provider’s reimbursement.

Outsource Strategies International.

Being an experienced medical billing and coding company in the U.S., OSI is dedicated to staying abreast of the latest industry guidelines. Our services provide comprehensive support for the success of your practice.

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