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 the epidermis, dermis, or subcutaneous tissues; and
- does not involve deeper structures.
Code these closures with 12001-12021, confirms Dilsia Santiago, CCS, CCS-P, a coder in Reading, Pa. And remember that simple repair includes “local anesthesia, and chemical or electrocauterization of wounds not closed,” she continues.
Example: The ED physician examines a 22-year-old patient’s scalp wound …
Utilizing prolene sutures the physician closes a 2.3 cm single-layer wound. On the claim, you’d report 12001 (Simple repair of wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) for this encounter.
Simple, Intermediate: Does It Really Matter?
If you’re interested in more money for the same service, knowing the difference between simple and intermediate repairs is vital.
Example: Let’s say the ED physician closes a 2.9 cm laceration on a patient’s forehead. You report 12013 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm) for the service; encounter notes justify an intermediate repair because the physician needed to perform layered closure of the wound, however, so you should have opted for 12052 (Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm).
Payout: The wrong code here will cost you about $90. The 12013 code pays about $111 (3.08 transitioned facility relative value units [RVUs] multiplied by the 2009 Medicare conversion rate of 36.0666). You’ll corral about $191 for 12052, however (5.08 RVUs multiplied by 36.0666).
OK, How Do Simple and Intermediate Differ?
Simple repairs involve only the epidermis, dermis, and subcutaneous tissues; intermediate repairs also involve the superficial fascia (non-muscle).
Code these closures with 12031-12057, says Santiago.
Good tip: When looking at the encounter notes, if coders can tell that the physician is “in the fascia, then it’s not simple but intermediate,” says Santiago. There are two main types of intermediate repair scenarios. In the first, the notes typically indicate that the physician performed a layered closure of a deeper area on the patient’s wound.
“Depth is best reported by anatomical level instead of measured distance,” says Jeffery Linzer, MD, FAAP, FACEP, associate medical director for compliance for the Emergency Pediatric Group at Children’s Healthcare of Atlanta at Egleston.
Type 1 example: The ED physician performs a level three E/M service for a patient with an open cut on his forearm. Notes indicate that the injury “penetrated the dermis, through to the fascia. No infection present.” Using a layered repair the physician closes the deeper tissues with vicryl and the skin with nylon sutures as part of 2.6 cm repair; she then dresses the wound.
This is an intermediate repair due to wound depth. On the claim, report the following:
- 12032 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 cm to 7.5 cm) for the repair
- 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity …) for the E/M
- modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99283 to show that the E/M and repair were separate services.
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