Laceration Repair Coding, Boost Pay-Up...communicate information about CPT coding, conventions, guidelines and rules in an educational format and manner. • The authors are not providing

Training Session Handouts

Laceration Repair Coding, Boost Pay-Up Expert Strategies to Improve Laceration Repair

Coding Accuracy and Reimbursement

Presented by: Gloryanne Bryant, RHIA, CDIP, CCS, CCDS,

AHIMA Approved ICD-10-CM/PCS Trainer

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Laceration Repair Coding: Improve Accuracy and Reimbursement

www.codingleader.com 1

CPT Coding Laceration Repairs

Coding LeaderWebinar

SpeakerGloryanne Bryant, RHIA, CDIP, CCS, CCDSAHIMA‐Approved ICD‐10 PCS/CM Trainer •She has 40 years of experience in HIM Coding.•Gloryanne is the Past‐President of CHIA and a volunteer leader on State and National level. •She is a sought‐after advisor, mentor, national educator, speaker and author on healthcare compliance, reimbursement, CDI, physician querying, coding regulations (ICD‐10‐CM/PCS, CPT, MS‐DRGs, and HCCs), coding compliance and ethics.



Disclaimer• This material is designed and provided to

communicate information about CPT coding, conventions, guidelines and rules in an educational format and manner.

• The authors are not providing or offering legal advice but, rather, practical and useful coding information and tools to achieve compliant results in the area of CPT coding.

• Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful.

• Applying best practice solutions and achieving results will vary in each hospital/facility and clinical situation

Goals/Objectives

• Review clinical aspects of laceration/wounds• Enhance knowledge of good documentation for Laceration Repair (Closure)

• Improve understanding of CPT guidelines for coding laceration repairs

• UnderstandMultiple Laceration Repair CPT Coding

• Review and analyze Case Scenario’s with Discussion



CPT®

• The Current Procedural Terminology (CPT) codeset is a medical code set maintained by the American Medical Association through the CPTEditorial Panel.

• CPT is a registered trademark of the American Medical Association.

• Use of the CPT codes and descriptions during this program is for educational purposes only.

Clinical Background• A laceration should be evaluated and the bleeding controlled using

direct pressure. • A patient history should be obtained, including mechanism and

time of injury and personal health information (e.g., human immunodeficiency virus and diabetes status; tetanus immunization history; allergies to latex, local anesthesia, tape, or antibiotics).

• A careful exploration of the laceration should be performed to determine severity and whether it involves muscle, tendons, nerves, blood vessels, or bone.

• Baseline neurovascular and functional status of the involved body part should be evaluated before repair. Lacerations that expose underlying tissue or continue bleeding should be repaired, although some less severe wounds (e.g., simple hand lacerations that are less than 2 cm long) may heal well with conservative management.



Clinical Background (cont.)

• Sutures, tissue adhesives, staples, and skin‐closure tapes are options in the outpatient setting.

• Suturing techniques, included simple, running, and half‐buried mattress (corner) sutures.

• Wound evaluation, preparation, and appropriate repair techniques; when to refer for surgical treatment; and how to provide follow‐up care.

Clinical Background (cont.)• Suture techniques: a.

single interrupted closure, b. running “baseball” closure, c. subcuticularrunning closure.

• Traditionally, the suture begins in the middle of the wound, with the remaining stitches placed symmetrically until the wound is closed.




• Suture material:• Absorbable sutures, such as polyglactin 910 (Vicryl), and

polyglycolic acid (Dexon) and Poliglecaprone 25 (Monocryl), are used to close deep, multiple‐layer lacerations. – Cost effective

• Although these sutures absorb at varying rates, they all usually absorb within four to eight weeks.

• Nylon, monofilament nonabsorbable sutures (e.g., polypropylene [Prolene]) must eventually be removed.

• The wound dehiscence rate, cosmetic results, and infection risk of absorbable sutures is comparable to that of nonabsorbable sutures, and absorbable sutures.

• Silk sutures are no longer used to close the skin because of their poor tensile strength and high tissue reactivity.


• Vertical mattress sutures.

• Tissue adhesive




• The goals of laceration repair are to achieve hemostasis, avoid infection, restore function to the involved tissues, and achieve optimal cosmetic results with minimal scarring.

• Definitive laceration management depends on the time since injury, the extent and location of the wound, available laceration repair materials, and the skill of the physician.

• (Source: AAFP)

CPT Coding Basics (con’t)

• Introduction – general information for coding professionals• Sections

– – Major Subsections• Categories

– – Subcategories• Appendices• Index• Guidelines – beginning of each section• Notes – subsections, headings, codesThe Coding professional will always reference the CPT manual for notes and/or directions.

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CPT Basics (con’t)• Punctuation CPT Conventions• Boldfaced Type

– – CPT category, subcategory, and code

• Numbers– – Main terms in Index

• Italicized Type– – See cross-reference term in Index

• Cross‐reference– – Directs coding professionals to another index entry

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CPT Indentions

• Stand alone CPT codes vs Indented codes – Stand alone = complete description– CPT Has info before AND after

• Indented Codes– Used to save space– Some descriptions NOT completely printed– CPT Code description is indented and coder

must refer back to common portion (BEFORE ;)

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Integral Services to the Procedure (not coded separately)

• Local, topical, regional anesthesia– When done by physician performing

• The procedure itself• Sedatives

– When done by Physician doing procedure• Applying, managing, removing post‐op dressings/analgesic devices

• More details in Surgery Guidelines15

Integral Services (con’t)

• Cleansing, shaving, prepping skin;• Documenting pre‐, intra‐, post‐op procedures;• Draping/positioning of patient;• Inserting/removing drains, suction devices, dressings, pumps into SAME site;

• Inserting IV access for meds;• Irrigating wound;• Providing surgical approach, closure, cultures, supplies (unless CMS states otherwise).

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Separate Procedures

• Procedures commonly carried out as an INTEGRAL component of another service.

• Codes with “separate procedure” in description should NOT be reported in addition.

• IF “separate procedure” is done along or is unrelated/distinct, it may be reported with modifier ‐59.

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AMA CPT Assistant

• CPT Official Resource & Guidance;• Published Monthly (via paid subscription);• Review and understand the content;• Ask questions and provides answers.

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This resources is a MUST for any outpatient coding.



CPT Coding Basics (Steps)1. Read the source document and code only from

the information listed. NEVER assume any additional information.

2. Review the operative report closely when selecting procedures to be coded.

3. Use the information available in the record, analyze the procedure statement provided by the physician.

4. Identify the main term and applicable subterms for the procedure(s) or service.

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CPT Symbols• Indicates a new procedure number/code was added to the CPT nomenclature•▲Indicates a code revision has resulted in a substantially altered procedure descriptor Indicates a CPT add‐on code• Indicates a code that is exempt from the use of modifier 51 but is not designated as a CPT add‐on procedure or service• ►◄Indicates revised guidelines, cross‐references, and/or explanatory text•Indicates a code that typically includes moderate sedation• Indicates a code for a vaccine that is pending FDA approval• # Indicates a resequenced code.• Indicates telemedicine services (with modifier 95)



Unlisted Procedure/Service

• Service is provided, BUT not listed in CPT• All Unlisted procedures are listed in:

– Guidelines– End of subsections of major sections– APPENDIX listing all “unlisted CPT codes”

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Modifiers • The use of modifiers (either AMA or CMS‐defined modifiers)

requires explicit understanding of the purpose of each modifier. –especially Hospital Outpatient setting.– Physician specific modifiers

• Modifiers designed specifically for use with the correct coding and mutually exclusive code pairs.– -E1 through -E4– -FA, -F1 through -F9– -LC, -LD, -RC– -LT, -RT, – -TA, -T1 through -T9, – -25, -58, -59, -78, -79, and -91.

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Modifiers (con’t)• Modifiers explain the situation of the procedure and allows

for payment to be made under certain circumstances based upon the modifier definition or meaning.

• 25 Significant separate• 50 Bilateral procedure• 51 Multiple procedures• 59 Distinct procedure service• Left or Right (LT or RT) laterality designation• In order for a payer to recognize that the procedure was

performed on the same date as the evaluation and management service and that it was separate and distinct, it is necessary to append modifier 25 to the E&M CPT code in order to be considered for separate payment.

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Modifier 51 & Modifier 59“Distinct Procedural Service”: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non‐E/M services performed on the same day.• Documentation must support a …

– different session,– different procedure or surgery,– different site or organ system,– separate incision/excision– separate lesion,– separate injury (or area of injury in

extensive injuries)– not ordinarily encountered or

performed on the same day by the same individual.”

• Source: 2018 CPT Codebook

• NOTE: CMS has published an article on Modifier 59 an the link is listed on the reference slide.

• When multiple procedures, other than E&M services, Physical Medicine and Rehabilitation services or provision of supplies (e.g. vaccines), are performed at the same session by the same individual, the primary procedure or service may be report as listed. The additional procedure (s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s).

• Note: this modifier should not be appended to designated “add‐on” codes (see Appendix D in CPT book)

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Modifiers (con’t)• Example: “A 2cm. Intermediate laceration repair is performed on the right arm of a 3‐year‐old patient.”

• What modifier if any should be added to the CPT procedure code? Answer: __RT ______

• Would modifier 59 be assigned?___No____

• ANSWER: No, modifier 59 is not needed or required.

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Medicare Modifiers• Modifier XE: Separate Encounter: A service that is

distinct because it occurred during a separate encounter.

• Modifier XP: Separate Practitioner: A service that is distinct because it was performed by a different practitioner.

• Modifier XS: Separate Structure: A service that is distinct because it was performed on a separate organ/structure.

• Modifier XU: Unusual Non‐Overlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service.



Surgical Documentation

• Accurate and complete coding should paint a picture of the patient’s encounter – Only documented services may be coded – The physician documentation is key to correct code assignment and appropriate reimbursement

– Does the documentation support not only the code(s) assigned, but the medical necessity?

Documentation

• Complexity: simple, intermediate or complex– Contaminated wound, debris

• Anatomic location• Length in centimeters



Documentation Requirement: Complexity (cont.)

• Search/review the documentation for clues as to the complexity of repair, statements such as “layered closure,” “involving subcutaneous tissue,” and/or “removal of debris,” “extensive cleansing,” etc., point to an intermediate repair. If there is a lack of these details, or a statement of “single layer closure,” suggests a simple repair.

Documentation Requirement: Location

• Location Subcategory• After you’ve determined if the repair is simple (12001‐

12018), intermediate (12031‐12057), or complex (13100‐+13153), narrow your code selection by the documented location of the wound(s) repaired. This is best done by referring to the CPT® code descriptors. For instance, intermediate repairs are grouped into anatomic categories:

• 12031‐12037: scalp, axillae, trunk, and/or extremities (excluding hands and feet)

• 12041‐12047: neck, hands, feet, and/or external genitalia• 12051‐12057: face, ears, eyelids, nose, lips, and/or mucous

membranes



Documentation Requirement: Size• Per CPT®, “The repaired wound(s) should be measured

and recorded in centimeters, whether curved, angular, or stellate [star shaped].”

• For an intermediate repair (12031‐12057) of a leg wound (12031‐12037, extremities) measuring 10 cm, you would select 12034 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm.

• NOTE: Complex repair codes (unlike either the simple or intermediate repair codes) employ add‐on codes to describe wounds greater than 7.5 cm. – Code/Report as many units of the add‐on codes as necessary to describe the size of the wound repaired.

Laceration Repair DocumentationDocumentation Needed for Correct Coding:Type of repair being performed;Site or body part is involved; Length of the repair (in centimeters); If extensive decontamination or debridement performed;

The number of square centimeters debrided; If there was involvement of nerves, blood vessels or tendons.

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Laceration Repair• Laceration – a ragged skin tear often made by a blunt object or

machinery accidents. • Lacerations sometimes have the added complication of the

tissues being crushed due from the nature of the injury. These types of wounds are also prone to infection.

• The wound repair codes found in the CPT, surgery section, Integumentary system subsection, are to be used only when the physician uses sutures, staples and/or tissue adhesives to close a wound.

• If the physician only uses adhesive strips to close the wound, the CPT directs the physician to use the appropriate evaluation and management code (99201 – 99499). The more simple procedure would be billed an evaluation code rather than a procedure.

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Laceration Repair• Causes a change in

function surrounding the area of the laceration.

• Is located in an area where an unsightly scar is undesirable.

• A laceration should be repaired if it:

• Continues to bleed after application of pressure for ten to fifteen minutes.

• Is more than one‐eighth to one‐fourth inch deep.

• Exposes fat, muscle, tendon, or bone.

• Is dirty or has visible debris in it.

34



Laceration Repair (con’t)• The three types of classifications for the wound repair (closure)

codes found in the surgery section of the CPT are simple, intermediate, or complex.

• Involvement of nerves, blood vessels and tendons, report under the appropriate system (Nervous, Cardiovascular, Musculoskeletal) for repair of these structures.

• NOTE: Simple ligation of vessels in an open wound is considered as part of any wound closure.

• Simple Repair: Is used when the wound is superficial; e.g., involving primarily the epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures, and requires simple one layer closure. This includes local anesthesia and chemical or electrocauterization of wounds not closed.

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Simple Laceration Repair (cont.)• 12001‐12007 (12001, 12002, 12004, 12005, 12006, 12007) The

physician performs wound closure of superficial lacerations of the scalp, neck, axillae, external genitalia, trunk, or extremities using sutures, staples, tissue adhesives, or a combination of these materials.

• A local anesthetic is injected around the wound and it is cleansed, explored, and often irrigated with a saline solution. The physician performs a simple, one‐layer repair of the epidermis, dermis, or subcutaneous tissues.

• For multiple wounds of the same complexity and in the same anatomical area, the length of all wounds sutured is summed and reported as one total length. Report 12001 for a total length of 2.5 cm or less; 12002 for 2.6 cm to 7.5 cm; 12004 for 7.6 cm to 12.5 cm; 12005 for 12.6 cm to 20 cm; 12006 for 20.1 cm to 30 cm; and 12007 if the total length is greater than 30 cm. (Coder’s Desk Reference)



Intermediate Laceration Repair (con’t)

• Intermediate Repair: Includes the repair of wounds that, in addition to the above, require 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. Single‐layer closure of heavily contaminated wounds that require extensive cleaning or removal of particulate matter also constitutes an intermediate repair. CPT codes 12031‐12057.

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Intermediate Repair (cont.)• 12031‐12037 (12031, 12032, 12034, 12035, 12036, 12037) The physician

performs a repair of a wound of the scalp, axillae, trunk, and/or extremities (except hands and feet) using sutures, staples, tissue adhesives, or a combination of these materials to perform a layered closure. Due to deeper or more complex lacerations, deep subcutaneous or layered repair techniques are required.

• A local anesthetic is injected around the laceration, and the wound is cleansed, explored, and often irrigated with a saline solution. Extensive cleaning or removal of foreign matter from a heavily contaminated wound that is closed with a single layer may also be reported as an intermediate repair. For multiple wounds of the same complexity and in the same anatomical area, the length of all wounds repaired is summed and reported as one total length.

• Report 12031 for a total length of 2.5 cm or less; 12032 for 2.6 cm to 7.5 cm; 12034 for 7.6 cm to 12.5 cm; 12035 for 12.6 cm to 20 cm; 12036 for 20.1 cm to 30 cm; and 12037 if the total length is greater than 30 cm. (Coder’s Desk Reference)



Complex Laceration Repair (con’t)

• Complex Repair: Includes the repair of wounds requiring more than layered closure, viz., scar revision, debridement (e.g. traumatic lacerations or avulsions), extensive undermining, stents, or retention sutures. Necessary preparation includes creation of a limited defect for repairs or the debridement of complicated lacerations or avulsions. CPT codes 13100‐13160.

• NOTE: Complex repair of nerves, blood vessels or tendons are coded in addition to the repair procedure and modifier ‐59 applies.

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Complex Repair (cont.)• 13100‐13102 (13100, 13101, 13102) The physician repairs

complex wounds of the trunk. The physician performs complex, layered suturing of torn, crushed, or deeply lacerated tissue.

• The physician debrides the wound by removing foreign material or damaged tissue. Irrigation of the wound is performed and antimicrobial solutions are used to decontaminate and cleanse the wound. The physician may trim skin margins with a scalpel or scissors to allow for proper closure. The wound is closed in layers.

• The physician may perform scar revision, which creates a complex defect requiring repair. Stents or retention sutures may also be used in complex repair of a wound. Reconstructive procedures, such as utilization of local flaps, may be required and are reported separately. Report 13100 for wounds 1.1 cm to 2.5 cm; 13101 for 2.6 cm to 7.5 cm; and 13102 for each additional 5 cm or less.(Coder’s Desk Reference)



Laceration Repair (con’t)Repaired wound should be measured in centimeters whether curved, angular, or stellate.Add together the length of all lacerations for the same anatomical grouping, for the same type of repair classification. For example:

• A 2 cm laceration on the forehead and a 2 cm laceration on the nose, both requiring simple closure. 2 cm + 2 cm = 4 cm. Assign one code: 12013, simple repair of superficial wounds of face 2.6 cm to 5.0 cm.

• Review the CPT description and the anatomic locations.

• A 2 cm laceration on the forehead requiring simple closure, and a 2 cm laceration on the cheek, requiring intermediate closure. Assign two codes: 12051, intermediate repair of wounds of face, 2.5 cm or less and 12011, simple repair of superficial wounds of face, 2.5 cm or less.

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Wound Size: Conversion Table• Millimeters/Inches Centimeters/Sq.Centimeters

• 1 m m = 0 . 1 c m• 10 m m = 1 c m

• 0 . 3 9 3 7 i n = 1 c m

• 1 i n = 2 . 5 4 c m

• 0 . 1 6 s q i n = 1 s q c m

• 1 s q i n = 6 . 4 5 2 s q c m



Laceration Repair (con’t)

• Sequencing: When more than one classification of wounds is repaired, list the more complicated as the primary procedure, and the less complicated as the secondary procedure.

• Decontamination and/or debridement is considered a separate procedure only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when debridement is carried out separately without immediate primary closure.

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Laceration Repair Example

• A five‐year‐old female patient came into the emergency department after she fell off a swing and scraped her arm when she landed on some branches on the ground.

• The physician examined the abrasion and documented that she required and performed a 4.3 cm simple repair on her left arm.

• What CPT code would be assigned for this repair?– See Repair, closure, simple = check the descriptions

and the body part, then check the length.• CPT Code 12002 (including hands/feet)

– Adding the LT modifier

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Laceration Repair (con’t)• When two layers of sutures are placed in the skin ‐ one in the dermis

and one in the epidermis, is this considered a simple or intermediate repair in CPT?

• What you describe would be a simple repair. Both layers of sutures are technically in the skin, not the skin plus a subcutaneous tissue layer.

• The dermis and epidermis are both part of the "skin.“ In the Repair section of CPT, “intermediate” repair describes layered closure of a deeper layer of subcutaneous tissue such as fascia, subcutaneous fat or muscle, in addition to the skin and its aggregate structures. 45

Coding Multiple Repairs• The provider may repair several wounds in a single

session.• Determine the proper coding for each repair

individually. • Check if any repairs of the same complexity are

grouped to the same anatomic areas. If so, you should add together the lengths of the similar wounds and report them using a single, cumulative code. – “For example,” CPT® says, “add together the lengths of intermediate repairs to the trunk and extremities.”

• Do not combine wounds of different severity OR those that fall within separate anatomic locations (as defined by the relevant code descriptors).



Decontamination or debridement:• CPT® specifies, “Debridement is considered a separate

procedure only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when debridement is carried out separately without immediate primary closure.” [emphasis added]

• Wound repair does not include excision of benign (11400‐11446) or malignant (11600‐11646) lesions, but lesion excisionmay include would repair. Per CPT®, simple repairs are always included in lesion excision, but “Repair by intermediate or complex closure should be reported separately.”

• Medicare, via National Correct Coding Initiative edits, follows the same rules.

Tissue Adhesive

• Tissue adhesive (i.e. Dermabond) is a method of repair.

• Tissue adhesives can be applied more quickly, require no anesthesia, and eliminate the need for follow‐up because they slough off spontaneously within five to 10 days.

• They form a protective barrier to promote wound healing and may have antimicrobial effects



Tissue Adhesive (cont.)

• Application of tissue adhesive in laceration repair. Note the wound edges approximation and the thin layer of tissue adhesive.

• Wound dehiscence can occur so a recheck is often advised for 2 days later.

Exofin Tissue Adhesive

Tissue Adhesive (cont.)

• CPT Coding: CPT® directs you to report Repair (Closure) codes 12001‐13160, as appropriate to the type (simple, intermediate, or complex), location, and length of the wound “to designate wound closure utilizing sutures, staples or tissue adhesives (eg, 2‐cyanoacrylate), either singly or in combination with each other, or in combination with adhesive strips.”



Tissue Adhesive Application

Steps to Surgical CPT Coding• Review the title or header of the procedure report or

note; (do not code from the title or header)• Review the CPT® codebook (start in the Index);• Review the full report/documentation;• Make a preliminary code selection;• Review the guidelines (for the preliminary codes);• Check and determine if you need to Add any needed

modifiers;• Review your code selection one last time and if correct

then assign/report the code.



Time for some CPT Coding!

• We will now go over a few coding scenario’s.

Case Scenario #1• A 45 year old patient presents to the physician’s office

with a 2.5 cm laceration to his left hand and a 2.3 cm laceration to his right hand.

• The wounds are cleansed, examined and a determination is made that they can be repaired via simple repairs.

• Simple repair of left hand 2.5 cm is performed and a 2.3 cm simple repair of the right hand is performed with a light dressing applied. Instructions for the wounds and dressing is provided. The patient will contact the office if there are signs of infection.

• What CPT code (s) would be assigned?



Case # 1 Discussion

• Patient presents to the physician’s office with a 2.5 cm laceration to his left hand and a 2.3 cm laceration to his right hand. Both lacerations require simple repairs.

Case Scenario #2• A patient presents to the physician’s office with an

open wound to the scalp. The wound is cleaned, examined and a suture repair is determined to be needed.

• The wound is cleansed again and measured. The provider diagnoses the patient with a 2.5 cm laceration and performs an intermediate closure of the wound using sutures in layers. A loose dressing was applied and instructions were given to the patient. The patient is to return to the office in 5 days.

• What CPT code(s) would be assigned?



Case #2 Discussion

• A patient presents to the physician’s office with an open wound to the scalp.

• The provider diagnoses the patient with a 2.5 cm laceration and performs an intermediateclosure of the wound.

Case Scenario #3

• A 16 year old fell into a glass window and cut both arms, hand and face (near forehead). There was active bleeding and the parents applied pressure while taking him to the ER.

• At the ER the patient was assessed, wounds were cleaned for examination. The provider determined that there was a 3.4 cm laceration on the left hand that needed intermediate suturing with absorbable material and using local anesthesia (lidocaine). The right arm had two lacerations, one 1.4 and the other 2.7 both required a simple layer suture repair (nonabsorbable) which was performed.

• There was an additional laceration on the right hand which required repair via simple suture 1.5 cm. The laceration on the 2.8 cm face area was repaired with tissue adhesive. Dressings were applied and instructions regarding keeping the wounds clean and dry. A recheck will be scheduled for 4 days from now.

• What CPT code(s) would be assigned?



Case #3 Discussion

• The provider determined that there was a 3.4 cm laceration on the left hand that needed intermediate suturing with absorbable material and using local anesthesia (lidocaine). The right arm had two lacerations, one 1.4 and the other 2.7 both required a simple layer suture repair (nonabsorbable) which was performed.

• There was an additional laceration on the right hand which required repair via simple suture 1.5 cm. The laceration on the 2.8 cm face area was repaired with tissue adhesive. Dressings were applied and instructions regarding keeping the wounds clean and dry. A recheck will be scheduled for 4 days from now.

Outpatient Querying

• When documentation in incomplete, inconsistent, missing, etc. we should query the provider for clarification.

• Use of AHIMA query templates (see the AHIMA Practice Brief “Guidelines for Achieving a Compliant Query Practice” and AHIMA’s Query Toolkits.



Next Steps . . .

• Review the CPT guidelines regarding repair closures – adding anatomic locations together within the same grouping.

• Read and Watch documentation closely.• Audit some encounters and validate CPT code assignment.

• Educate both coding staff and providers.• Querying may be needed, so have a compliant format and process in place.

Summary• Lacerations (wounds) come in different locations, many different shapes and sizes.

• Repair (closure) in CPT has three levels:– Simple– Intermediate– Complex

• Instructions include adding together lengths of wounds in the same classification and anatomic location from the same code descriptor.

• Use the appropriate modifier when needed.



Questions

• Are there any questions?

Thank You!!!



References/Resources

• AMA CPT codebook 2018• AMA CPT Assistant• https://www.aapc.com/blog/26374‐proper‐coding‐for‐tissue‐adhesives/

• https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/modifier59.pdf

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Laceration Repair Coding, Boost Pay-Up...communicate information about CPT coding, conventions, guidelines and rules in an educational format and manner. • The authors are not providing