Wound repair, most commonly documented as suture of a laceration, is one of the most common procedures performed in emergency departments (EDs) throughout the U.S. today. This is why it's important that coders classify and code these services appropriately, based upon the documentation in the medical record.
The following code ranges are used to report wound repairs:
12001 - 12018, Simple repair of superficial wounds
12031 - 12057, Intermediate repair of wounds
13100 - 13153, Complex repair of wounds
There are a number of steps that need to be taken before you can determine the correct code assignment for wound repairs. The first step is to determine the type of repair performed. Was it simple, intermediate or complex? Definitions of these terms are found in the CPT book, below the "Repair (Closure)" heading and include the following:
Simple: Superficial wounds of the epidermis, dermis or subcutaneous tissue without significant involvement of deeper structures. It requires simple one-layer closure or suturing.
Intermediate: Wounds that require layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin closure described under simple repair. Single-layer closure of heavily contaminated wounds requiring extensive cleaning or removal of particulate matter is included under intermediate repair.
Complex: Wounds requiring more than layered closure, for instance scar revision, debridement, extensive undermining, stents or retention sutures. Complex repair may include creation of the defect and necessary preparation for its repair or the debridement and repair of complicated lacerations.
The coder must review the documentation carefully to determine the type of repair performed because in the majority of instances the physician will not document simple, intermediate or complex.
The next step is to identify the body site or sites that are repaired. CPT organizes repairs of similar types and anatomical sites together so the extra work involved in suturing a laceration on the face, for example, can be classified differently than one involving the neck. Face, ears, eyelids, nose, lips and/or mucous membranes are grouped together in one range of codes, while scalp, neck, axillae, external genitalia, trunk and/or extremities are grouped in another. It's important for the coder to review these groups carefully, because they do differ slightly between simple, intermediate and complex repair.
While the vast majority of wound repair codes are in the integumentary system portion of CPT, if the tissue repaired is different, or necessitates differing techniques, different codes may be necessary. For example, repairs of the tongue are found in the digestive system of CPT, and not the integumentary. The wound repair codes discussed here would not be assigned.
As the final step, the length of the wound repaired must be identified. CPT identifies the length in centimeters. If the wound is documented in inches instead of centimeters, the coder must translate it to centimeters. The following may be helpful if the wound length is documented in inches.
1 inch = 2.5 cm
1 inch to 2 15/16 inches = 2.6 to 7.5 cm
3 to 4 15/16 inches = 7.6 to 12.5 cm
4 15/16 to 7 7/8 inches = 12.6 to 20.0 cm
7 15/16 to 11 13/16 inches = 20.1 to 30.0 cm
11 14/16 inches = over 30.0 cm
After identifying the length of each wound repaired, the following questions should be answered:
1. Do the wounds involve anatomical sites that are in the same group?
2. Were the wounds repaired using the same technique: simple, intermediate or complex repair?
If the answer is "yes" to both questions then, per CPT coding guidelines, the lengths of the wounds repaired should be added together and only one CPT code is assigned. For example, a patient with a 3 cm laceration on the left arm and a 2.5 cm laceration of the scalp are repaired with simple one-layer closure. Because both scalp and arm are included in the same group and both were documented as simple repairs, 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, is assigned.
It's also important to note that if the documentation indicates the repair of a simple wound using tissue glue/adhesive such as Dermabond the repair should be coded to the appropriate repair code from range 12001-12018. On the other hand, wound closures utilizing adhesive strips, such as Steri-strips or butterflies, should be coded using the appropriate E/M code.
Debridement services provided in conjunction with wound repairs are not coded separately unless the documentation specifies that gross contamination requires prolonged cleansing or when appreciable amounts of devitalized tissue is removed.
Review all CPT coding guidelines related to wound repairs and take the following quiz:
1. A patient comes into the ED after sustaining injuries in an automobile accident. The patient required the repair of three superficial lacerations; 3.0 cm cheek, 6.5 cm scalp, and 3.5 cm neck. Also repaired was 4.5 cm scalp wound requiring layered closure.
a. 12032, 12004, and 12013
b. 12032, 12004
c. 12032, 12005
d. 12005, 12013
2. A 42-year-old male was involved in a motorcycle accident. He suffered a 6 cm deep laceration of his forearm, which was repaired with tissue adhesive and a layered suture repair. The appropriate CPT codes are:
c. 12032, 12002
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, facility solutions, Ingenix, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix (www.ingenix.com).
CPT is a registered trademark of the American Medical Association.
1. a. The codes assigned in this case are 12032, 12004 and 12013. The length of the superficial scalp and neck wounds would be added together because these are the same group of sites and the same type of repair making it a 10.0 cm simple repair. Although the second scalp wound would belong to the same group of sites, its length is not added to the other two lacerations because it falls into a different repair classification (intermediate). The cheek laceration would be coded separately because it is in a different group of sites than the other simple repairs.
2. b. Because the repair was considered intermediate (layered closure) assign code 12032 for wounds between 2.6 and 7.5 cm. No complex repair or reconstructive procedures were performed. A separate code would not be assigned for the tissue adhesive.