Pediatric | Use Four Steps to Accurately Select Laceration Repair Codes

1. Classification: determine whether a repair is simple (superficial), intermediate (deeper layers), or complex (not likely in an ambulatory pediatric practice)
2. Size: measure the size in centimeters of the repaired wound
3. Location of the injury: should be used to arrive at the final code selection
4. Number: if multiple.

The site groupings differ slightly for each classification:

• Simple repair (12001-12021) includes two basic groups: 12001-12007 (scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]) and 12011-12018 (face, ears, eyelids, nose, lips and/or mucous membranes).
• Intermediate repair includes three groups: 12031-12037 (scalp, axillae, trunk and/or extremities [excluding hands and feet]), 12041-12047 (neck, hands, feet and/or external genitalia), and 12051-12057 (face, ears, eyelids, nose, lips and/or mucous membranes).

Note: For multiple laceration repairs, add lengths within each classification from sites in the same grouping. For example, add two simple laceration repairs on the arm, but do not add one simple laceration on the face and one simple laceration on the arm, or one simple laceration on the face and one intermediate laceration on the face.

Case Study

An 8-year-old boy fell off his bike and has a 2-cm superficial laceration on the forehead, a 1-cm-deep laceration on the forehead, a 2-cm superficial laceration on the forearm, and a 2-cm superficial laceration on the knee. The pediatrician elects to perform the repairs in the office.

List laceration repair codes in order of severity, explains Jeffrey Linzer Sr., MD, FAAP, MICP, professor of pediatrics at Emory University, AAP representative to the ICD-9-CM editorial advisory board, and AAP coding and reimbursement committee liaison.

In this case, one laceration is intermediate; the others are all simple. The deep laceration on the forehead requires a two-layer repair. Because it is the only intermediate repair on the face, and it's less than 2.5 cm, report this repair with 12051* (Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less), says Linzer, who is also director of emergency medicine at Children's Healthcare of Atlanta and Hughes Spalding Children's Hospital. Use 873.42 (Other open wound of head; face, without mention of complication; forehead) for the diagnosis to accompany the repair.

Do not add the two facial lacerations, because one is intermediate and one is simple. Code the other facial laceration next. It is only a one-layer repair, which qualifies as simple, and it's less than 2.5 cm. Report 12011* (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less). Again, use 873.42.

Both other lacerations forearm and knee are single-layer repairs. In this case, two simple repairs on an extremity can be added. Because the total repaired length is 4 cm, code 12002* ( 2.6 to 7.5 cm). Use 881.00 (Open wound of elbow, forearm, and wrist; without mention of complication; forearm) for the forearm and 891.0 (Open wound of knee, leg [except thigh], and ankle; without mention of complication) for the knee.

Whether the lacerations are sutured or repaired by adhesive (Dermabond), the code is the same. CPT now includes adhesive in its introductory language to laceration repair (\Use the codes in this section to designate wound closure utilizing sutures" staples or tissue adhesives [e.g. 2-cyanoacrylate] \"). However do not consider Steri-strips to be laceration repair: Regardless of the classification size or site of laceration if applying a Steri-strip is the only repair bill only an E/M code not a repair code.

Additional E/M Code

If the pediatrician performs an evaluation to determine possible head injury internal injury and/or fractures an E/M code (99211-99215 established patient office visit) is appropriate Linzer says.

Some laceration repair codes are starred procedures; any E/M reported with them must have modifier -25 (Significant separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended explains Brenda Mason head biller with Northpoint Pediatrics Indianapolis. Some practices use modifier -25 on an E/M performed with laceration repair even if the repair code is not starred.

Also use modifier -51 (Multiple procedures) on the subsequent procedures. The case should be coded:

12051*
12011*-51
12002*-51
99211-99215 with modifier -25 appended.

If possible use a different diagnosis code for the E/M and the laceration. Also report V71.4 (Observation and evaluation for suspected conditions not found; observation following other accident) for the E/M. Mason also uses the E codes for the details of the accident. "I use these as secondary or tertiary diagnoses for supporting documentation " she says. In this case use E826.1 (Pedal cycle accident).

When billing an E/M service in addition to laceration repair consider extra work performed above what is included in the laceration repair. Every minor procedure has an inherent E/M component so it can't be assumed that an E/M service is always justified in addition to laceration repair. However if additional work is done that is separately identifiable justifying an extra fee and modifier -25 both services should be reported. CPT does not require that there be separate diagnoses just separate work.

The pediatrician not the coder must determine whether additional work was performed that justifies an E/M charge Mason stresses.

Laceration Repair Only

If the pediatrician repairs only the laceration no separate E/M code should be billed. For example a 15-year-old girl presents with a laceration on her fingertip caused while cutting carrots. There are no other injuries. The pediatrician sutures the laceration and bills laceration repair code 12001* (Simple repair of superficial wounds of scalp neck axillae external genitalia trunk and/or extremities [including hands and feet]; 2.5 cm or less) with no E/M.

Patient's Age

The younger the child the more likely a separate E/M will need to be performed because children cannot communicate the extent of their injuries. Below are some examples:

Rule out tendon damage: A 3-year-old cuts his hand on the edge of a garden tool. He is rushed to the pediatrician's office bleeding and has a 2-cm laceration. The pediatrician sutures the wound but must also check for nerve and tendon damage. Bill 12041* (Layer closure of wounds of neck hands feet and/or external genitalia; 2.5 cm or less) and 99211-99215 with modifier -25. Link 882.0 (Open wound of hand except finger[s] alone; without mention of complication) if there is no tendon involvement for both. If there is tendon damage use a separate diagnosis code 882.2 ( with tendon involvement) on the E/M.

Check for additional injuries: A 1-year-old boy just learning to stand pulls a dining-room chair on top of himself resulting in a small laceration on the forehead. The pediatrician sutures the laceration and also checks the child for other signs of head trauma performing a thorough neurological examination. Code 12011* (Simple repair of superficial wounds of face ears eyelids nose lips and/or mucous membranes; 2.5 cm or less) with 873.42 and 99211-99215 with modifier -25 appended with the same diagnosis; if a concussion occurred link 850.0 (Concussion; with no loss of consciousness) to the E/M.

Note: There is no code for a topical anesthetic; this is included in the service. However if lidocaine is used as a nerve block report 64450* (Injection anesthetic agent; other peripheral nerve or branch) or the appropriate code from the nerve block section (64400-64484).

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