There are two broad categories of reimbursement in emergency medicine: one for cognitive work involved in patient care represented by the evaluation and management (E/M levels 99281–99285) and critical care codes and the other for procedural services, which when documented and coded properly often result in significant and meaningful additional reimbursement over and above the E/M service.
Laceration repair is one of the most common procedures performed by emergency physicians, and their appropriate documentation and coding will ensure that you are fairly reimbursed for performing these important procedures. Lacerations are assigned CPT codes based on three elements: length, location, and complexity. Your documentation should accurately reflect each of these elements to allow the coder to assign the appropriate CPT code for the service.
Length of Wound
Wound repairs are in part categorized by length, which should be documented in centimeters. Increasing relative value units (RVUs) are associated with increasing repair length. Common categories are:
* 2.5 cm or less.
* 2.6 cm to 7.5 cm.
* 7.6 cm to 12.5 cm.
* 12.6 cm to 20.0 cm.
* 20.1 cm to 30.0 cm.
* 30.0 cm or more.
Regardless of whether the laceration is curved, angular, or linear, measure the repaired wound and make sure you report the length including tenths of centimeters to ensure appropriate reimbursement. Payment can take a big jump based on a small increase in length. Layered closure of wounds of scalp, axillae, trunk, and/or extremities that are 2.5 cm or less get CPT 12031 and 3.51 RVUs, with a Medicare reimbursement of $132.99. Layered closure of wounds of scalp, axillae, trunk, and/or extremities that are 2.6 cm to 7.5 cm get CPT 12032 and 4.57 RVUs, with a Medicare reimbursement of $173.16. That's a 30 percent increase in RVUs and reimbursement simply by measuring correctly!
When multiple wounds are repaired, the lengths of those repairs that are in the same complexity classification (simple, intermediate, or complex) and the same anatomic site grouping are added together. For example, the lengths of intermediate repairs of the hands and feet are added together and reported as one CPT code, but the lengths of repairs from different groupings of CPT-defined anatomic sites (e.g., nose and scalp) are reported separately using two CPT codes. Lengths of different complexity classifications (e.g., intermediate and complex repairs) are not added together.
Location of Wound
Wound repairs also are classified by their anatomic location. Simple repairs (CPT 12001–12021) have two major groups of locations that are categorized together. Any repairs in these areas should have their lengths added together. For example, if separate laceration repairs of a hand and foot are done, their length should be added together and reported as one repair. The two CPT-defined anatomic groupings for simple repairs are:
* Scalp, neck, axillae, external genitalia, and trunk and/or extremities (including hands and feet).
* Face, ears, eyelids, nose, lips and/or mucous membranes.
Intermediate repairs (12031–12057) have three major groups of locations:
* Scalp, axillae, trunk, and/or extremities (excluding hands and feet).
* Neck, hands, feet, and/or external genitalia.
* Face, ears, eyelids, nose, lips, and/or mucous membranes.
Location really does matter! A 5.2 cm scalp laceration coded as 12002 yields 2.94 RVUs while a 5.2 cm laceration of the forehead is reported with code 12014 and produces 3.75 RVUs, which is a 27 percent increase.
Wound repairs are classified as simple, intermediate, or complex. Simple repairs are the most common ones performed in the ED. This description is used for repairs that are superficial, such as those primarily involving epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures, and require simple one-layer closure. If there is more than one layer of closure, the repair would typically be coded as intermediate.
Intermediate repairs include wounds that require layered closure of one or more of the deeper layers of subcutaneous tissue, in addition to the skin (epidermal and dermal) closure. In day-to-day practice, when you place deep absorbable sutures (even just one), clearly document the dual-layer closure, and your work will be recognized with additional RVUs. For example, a 6 cm single-layer repair is assigned 3.75 RVUs while the same repair using a layered technique yields 5.05 RVUs (a 35% increase). If there is failure to document or code for a dual-layer closure, it will result in a simple repair classification and a loss of 1.3 RVUs.
In addition to dual layers, there is another way to classify and capture the high RVUs associated with intermediate repairs. Single-layer closure of heavily contaminated wounds that required extensive cleaning or removal of particulate matter also constitutes intermediate repair. If you are repairing a heavily contaminated wound, make sure to document the presence of extensive debris and cleansing, and have your work recognized with the intermediate repair codes.
Complex repairs are rarely performed in the ED. They include scar revisions and wounds that require extensive undermining, stents, or retention sutures.
Laceration repair is a common ED procedure, and appropriate documentation and coding will ensure fair reimbursement
Whenever possible, be sure to document at least two diagnoses when laceration repairs are performed. Without supporting documentation and accurate diagnosis reporting, many payers will unfairly bundle your laceration repair with the level of service and not pay for both the E/M service and the laceration repair. For example, document finger injury and finger pain in addition to the finger laceration diagnosis. Providing additional diagnoses helps support reimbursement for the cognitive work of a separate E/M level if performed.
Wound closures using sutures, staples, or tissue adhesives (e.g., 2-cyanoacrylate), either individually or in combination with each other, are reported using the CPT wound repair codes for most payers. An exception is for Medicare. Single-layer closures utilizing tissue adhesive are reported with a special unique Medicare G code (G0168), which can have a significant impact on reimbursement. Medicare pays approximately $26 for a straight adhesive repair while the lowest level laceration repair code reimburses roughly $100. Make sure your billers are properly identifying the payer when reporting these repairs.
Comparing E/M and Lacerations Repair Reimbursement
* CPT 12002 (2.6 cm simple finger laceration): 2.94 RVUs (Medicare payment of $111.40)
* CPT 99283 (Level III ED visit): 1.73 RVUs (Medicare payment of $66.55)
© 2007 Lippincott Williams & Wilkins, Inc.