The complex repair is also the only one of its type, and is coded 13121 Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm for the initial 7.5 cm, along with +13122 Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure) for the additional 1.5 cm (7.5 cm + 1.5 cm = 9 cm).
Open wound of scalp ICD-10-CM S01.00XA is grouped within Diagnostic Related Group (s) (MS-DRG v38.0): 604 Trauma to the skin, subcutaneous tissue and breast with mcc 605 Trauma to the skin, subcutaneous tissue and breast without mcc
Z48.0 ICD-10-CM Diagnosis Code Z48.0. Encounter for attention to dressings, sutures and drains 2016 2017 2018 2019 Non-Billable/Non-Specific Code. Type 1 Excludes encounter for planned postprocedural wound closure (Z48.1) Encounter for attention to dressings, sutures and drains.
Per CPT®, some single-layer closures may qualify as complex repairs, if the wound is “heavily contaminated” and requires “extensive cleaning or removal of particulate matter.”
If the wound had been 16 cm long, proper coding would be 13132 and 13133 x 2 (7.5 cm + 5 cm + 3.5 cm), and so on. Often, the clinician may repair several wounds in a single session.
Layer closure: Arm CPT CodesLayer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less (12031)Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm (12032)More items...
11403-excision, benign lesion, trunk, arms, legs, 2.1-3cm. Because both repairs are in the same anatomic group and both are intermedi- ate, they would be added together for coding purposes, and the code based on the 8.3 cm total-12034-layer closure of wounds of scalp, axillae, trunk, extremi- ties, 7.6-12.5cm.
After adding together the lengths of the simple repair procedures to the finger and arm, you would also bill CPT code 12005, “Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 12.6 cm to 20.0 cm.”
“Layered” repair typically refers to the use of absorbable sutures to bring together the dermis and underlying subcutaneous tissue, which both closes dead space (where otherwise infection/abscess may accumulate) and relieves tension on the epidermis.
Codes 11420- 11426 are used for the excision of benign lesions of the scalp, neck, hands, feet, and genitalia, whereas codes 11440-11446 are used for excision of benign lesions of the face, ears, eyelids, nose, lips, and mucous membrane.
Secondary wound closure, also known as healing by secondary intention, describes the healing of a wound in which the wound edges cannot be approximated. Secondary closure requires a granulation tissue matrix to be built to fill the wound defect.
S01.01XAICD-10 Code for Laceration without foreign body of scalp, initial encounter- S01. 01XA- Codify by AAPC.
Decontamination or debridement: CPT® specifies, “Debridement is considered a separate procedure only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when debridement is carried out separately without immediate primary closure.” [ ...
Code 90471 is used when the drug is administrated by a medical assistant or nurse and the patient does not see the physician at all. This code would also be used for any patient 19 years of age or older regardless if physician is present and does face-to-face counseling.
code 13160 (Secondary closure of surgical wound or dehiscence; extensive or complicated), which has a 90-day global period.
Complex closure means the repair of wounds requiring more than layered closure involving scar revision, debridement, extensive undermining, stent or retention sutures.”
12032 - CPT® Code in category: Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet)
CPT® Code 12041 in section: Repair, intermediate, wounds of neck, hands, feet and/or external genitalia.
CPT® Code 38525 in section: Biopsy or excision of lymph node(s)
14301 - CPT® Code in category: Adjacent tissue transfer or rearrangement, any area.
CPT® 12042 in section: Repair, intermediate, wounds of neck, hands, feet and/or external genitalia.
In other words, wounds requiring intermediate repairs are deeper than those requiring simple repair. Per CPT®, some single-layer closures may qualify as complex repairs, if the wound is “heavily contaminated” and requires “extensive cleaning or removal of particulate matter.”.
Some of these related procedures may not be separately reported; others may be separately reported, or separately reported only in specific circumstances. Here’s a quick rundown, based on CPT ® and the Medicare guidelines.
Wound repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions, but lesion excision may include would repair. Per CPT ®, simple repairs are always included in lesion excision, but “Repair by intermediate or complex closure should be reported separately.”.
Main term entries in the ICD-10-CM index for open wounds can be either the type of wound (e.g., puncture), or the term wound, open. Using either term will allow the coder to find the correct type of wound and anatomical location by using the indented subterms. For example, if you look up puncture wound of the abdomen in the index using the main term Wound, open and then go to the subterms Abdomen, wall, puncture, an instructional note will guide you to “see” Puncture, abdomen, wall.#N#Example 1:
Type of wound — Open wounds include: Abrasions: Shallow, irregular wounds of the upper layers of skin. Caused by skin brushing with either a rough surface or a smooth surface at high speed. Usually present with minor to no bleeding, with some pain that subsides shortly after initial injury.
Lacerations are generally caused by trauma or contact with an object. Incisions: Typically the result of a sharp object such as a scalpel, knife, or scissors.
Penetrating wounds can be life threatening, causing serious injury, especially if involving vital organs, major blood vessels, or nerves. Gunshot wounds: These are considered to be penetrating wounds that are exclusively caused by bullets from firearms (guns, rifles, etc.).
Depending on the depth and site of the wound, an incision can be life threatening, especially if it involves vital organs, major blood vessels, or nerves. Punctures: Small, rounded wounds that result from needles, nails, teeth (bites), or other tapered objects.
The puncture wounds on the patient’s hands are not gaping and I think the risks outweigh the benefits of any type of suture closure. The wounds are quite small and I think suturing them would likely increase their risk of infection. IMPRESSION: Dog bite.