Q: Wound Care and Laceration Repairs — “Could you do some scenarios with wound care at the next webinar? I am noticing a lot of those type questions on the CPC practice exams and am weak in that area. For example, an 11 year old girl fell from a chair and received two 3 cm lacerations to her left arm with embedded glass etc. etc. face, leg and arm needed layered closure wound repair and (whatever) needed superficial repair and (whatever) needed complex repair.”
A: The first thing that I wanted to clarify when we’re looking at this question is, this isn’t really wound care. Wound care is when we are providing care to the actual wound. Things like wound-vacs, packing, and all of that. What this is, is what we call a repair, and this is really a laceration repair. Laceration is just that, it’s a cut open on the skin and it can go multiple layers down, all the way to the bone in some situations.
When we look at coding for repairs, there are really three factors that you have to know. If you were to go in your CPT manual and you go to the repair section in the integumentary section, you’re going to find that there are three factors that determine which repair you need. The three pieces that you need to know. First of all, you’re going to have to know the type of the repair, is it simple, intermediate or complex? When we talk about simple, intermediate or complex, simple is just what it sounds like, simple. We’re just closing that back up. We’re using usually sutures to stitch it back up, sometimes we’re using butterflies, but it can’t be something as simple as Dermabond; if you read through the guidelines, it’s there.
VIDEO: Wound Care and Laceration Repairs | CPT Coding Tips
Intermediate, since it’s a little more complex than that, we may have to do a layered closure, we may have to get some dirt and debris out of there. A complex is just as it sounds, really complex; we had to do a lot of extensive undermining. We had to get all this dirt and all this dead skin and all of this other debris out of there. We got to do a layered closure, maybe we have to do rotations, something like that. Then, in addition to knowing what kind, what level, how big of a deal is it, we need to know where are we repairing, the anatomical location.
The third piece we have to know is the length of the laceration and your providers need to be documenting how big that laceration is. Good question I get a lot of the time is: “What if my provider didn’t say how big the laceration was?” Well, they shot themselves in the foot. It’s not that we can’t code for it, but we have to go with the smallest size available because most of them will say like under “2 cm.” If they didn’t tell us how big it was, all we can do, we know they had a laceration and we know we repaired it, and we usually know what level it was but we don’t know how big it was, we have to go with that small one.
Let’s look, I’ve got a scenario here in my answer sheet that we’re going to talk through, a little farther down in the page:
Laceration Repairs Scenario
We’ve got Martha. Martha is a 75-year- old female, she lost her balance and she fell. When she fell, she fell through the storm door at home. She has glass embedded in her right forearm and then her right hip. She also sustained lacerations to her right cheek, shoulder, and knee. So, we’ve got five different places that were injured; we’ve got the forearm, the hip, the cheek, the shoulder, and knee.
Her cheek laceration was 2 cm in length and we closed it with 6-0 Prolene. Her knee wound was 5.5 cm. Her shoulder wound was 7 cm. For the shoulder wound, we had to layer the closure. That should be, any time you see a layered closure, that should indicate to you that you’re going to have at least an intermediate repair. What that means is they had to layer the closure; they had to close maybe muscle and then skin, so they had to do multiple layers.
Her forearm was 11 cm and her hip laceration was 4 cm, both required cleaning and removal of glass. Again, they had to do more than just a simple closure. The hip laceration was closed using a layered closure of Vicryl and Prolene, and the forearm was a complex closure with some debridement going on there.
How to Code Laceration Repairs
So, when you go to code for this, what you’re going to do is ask those three questions. I had set mine up in a little table so we can talk easily.
- Where was it?
- Where were we?
- We had the cheek, the shoulder, the forearm, the knee and the hip.
- How big was each of them?
- So, I read through the note, and I plugged in the link of each one, next to that.
- What type of closure was each one of them?
- Simple, intermediate or complex?
You notice in my table I have two simples, two intermediates, and one complex. When you look at these codes in the CPT manual, they’re grouped. If you do the bubble and highlight thing, they’re grouped into three bubbles and that is because they group different body areas together and they’ll say, “Oh, you code the arms and the legs together. You code the face and certain parts of the face together.” Things like that.
For simple repairs, the cheek falls into the second bubble in your book, and the knee falls into the first one. So what we have, two simple repairs, they’re in two different anatomical locations even according to the CPT groupings, so we have to have two codes. For the intermediate repairs, the shoulder and the hip, both of those get grouped into the trunk or the extremities. My shoulder and my hip are both right off of my trunk before I go to the extremity.
For those purposes for a repair, if they’re in the same bubble, we add them together, we don’t code for them separately. You go, we coded for the first two separately because they were in different bubbles. But in this one they’re in the same bubble, they get added together so we take the 7 cm on the shoulder, the 4 cm on the hip. We add them together to get an 11 cm laceration with intermediate closure and we code the correct code for that, in this case it’s 12034.
We still have another closure left, we have one more, that complex closure. It gets coded all by itself because it’s a different level of closure. Think about it this way, you know where all of them were, you got to look at what was the level of closure – simple, intermediate or complex? So look at all your simples together, you look at all your intermediates together, look at all your complex together. And within each of those, do they all go to the same anatomical grouping for the codes? If so, they get added together. If not, they get coded separately.
What about RVUs?
Based on RVUs, that’s the relative value unit or the weight given to that code, which one pays more, which one is worth more work? And according to RVUs, I listed the answers for you there in the order that they go with, and the complex repair is going to go first, and then you’re going to have those intermediate repairs, then you’re going to have those simple repairs. According to the guidelines we also need a modifier 59, and that is because the guidelines say, “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, using modifier 59.”
Actually, what you would do is that 13121 would go first, and the remaining four codes (12034, 13122, 12011, 12002) would each have a modifier 59 on them to show that they are separate and significant from one another. They’re in different, they meet different requirements and different criteria so that the carrier doesn’t bundle all of them together and say, “You didn’t bill this right.”
That’s what when we talk about those examples that you’re going to see on the CPC exam and the practice exams, those are really repairs and it’s all about those three questions, what part of the body, how significant was the repair – simple, intermediate or complex; and how long, the length of the laceration?