Editor’s Note: Cutting through the red tape to make certain that you get paid for every dollar you earn has become more difficult than ever, particularly in our current climate of health care reform and ICD-10 transition. The ACEP Coding and Nomenclature Committee has partnered with ACEP Now to provide you with practical, impactful tips to help you navigate through this coding and reimbursement maze.
Explore This IssueACEP Now: Vol 35 – No 11 – November 2016
Question: What do I need to document for lacerations?
Answer: Three things are important to document for lacerations. First is the anatomical location (eg,left ring finger, right arm, face, neck, etc.). Different codes are used for different parts of the body and, consequently, different payment amounts. Second, the size of the repaired laceration determines the code. The ranges are 2.5 cm or less, 2.6 cm–5.0 cm, 5.1 cm–7.5 cm, 7.6 cm–12.5 cm, 12.5 cm–20.0 cm, 20.1 cm–30 cm, and more than 30 cm. It is always best to list the actual measured length of the wound after closure. Third, the complexity of the repair also determines the code (eg, simple, intermediate, complex). Complexity is determined by how extensive the cleaning or debridement was, if it was a layered closure, if it was undermined, or if a drain was required. Lastly, it is important to document if you used a wound adhesive to repair the laceration. Visit ACEP for more coding and reimbursement information.
Brought to you by the ACEP Coding and Nomenclature Committee.
Dr. Lempert is chief medical officer, coding policy, at TeamHealth, based in Knoxville, Tennessee.