Tag Archives | Reading Pa

Code Correct Closure Level With These Tips

All closures aren’t created equal; one of the nuances of coding these procedures is knowing how to distinguish one type from another. Read on for our experts’ advice on how to assess the three closure levels and assign the best codes.

A simple repair involves primarily the dermis and epidermis. It might involve subcutaneous tissues, but not deep layers.

How do you know when a closure might involve subcutaneous layers but is still considered a simple repair? Your provider’s documentation is the key. The difference is whether the wound is closed in layers or just a single layer, experts note. The provider might decide to include the subcutaneous layer in the closure but does so by bringing the needle through the dermis into the subcutaneous and back. That results in a single-layer closure rather than closing the subcutaneous layer first and then the dermis/epidermis second in separate closure techniques.

But “simple” doesn’t mean the repair is something anyone could do. Simple repairs involve one-layer closure, which helps set them apart from a standard E/M procedure. Simple repair also includes “local anesthesia, and chemical or electrocauterization of wounds not closed,” says Dilsia Santiago, CCS, CCS-P, a coder in Reading, Pa.

For example, if your dermatologist uses adhesive strips to close a laceration, consider it an E/M service that you’ll report with the best-fitting choice from codes 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient …) or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient …). Most Steri-strip applications are done by nursing staff; but even if the physician applies them, they’re included in the E/M service.

If, however, your dermatologist uses sutures, staples, or tissue adhesives to close the laceration, consider it a separate procedure. Choose…

Continue Reading

Wound Closure Coding: Make the Simple, Intermediate Distinction

Accounting for depth is a tricky task when coding closure.
Practices interested in ethically boosting their bottom line and getting $80 or more for the same closure repair need to walk the line that separates simple from intermediate.
What Makes a Repair “Simple”?
A wound closure is a simple repair if the procedure:

is simple;
is a single-layer closure involving […]

Related articles:

  1. Coding Education: Simple, Intermediate or Complex Closure?Correctly distinguish closure levels every time with this advice from…
  2. Simple Laceration Repair Code or E/M Code? Answer Could Cost Hundreds Not recognizing a laceration repair that’s included in an…
  3. Multi-Laceration Repair Coding Case StudiesDo you know when to code repairs that occur in…
Related Posts Plugin for WordPress, Blogger...
Continue Reading