Tips for coding suture removal:
Why ICD-10 codes are important
What is the correct ICD-10-CM code to report the External Cause? Your Answer: V80.010S The External cause code is used for each encounter for which the injury or condition is being treated.
ICD-10-CM stands for the International Classification of Diseases, Tenth Revision, Clinical Modification. Used for medical claim reporting in all healthcare settings, ICD-10-CM is a standardized classification system of diagnosis codes that represent conditions and diseases, related health problems, abnormal findings, signs and symptoms ...
Disruption of wound, not elsewhere classified 1 T81.3 should not be used for reimbursement purposes as there are multiple codes below it that contain a greater level of detail. 2 The 2021 edition of ICD-10-CM T81.3 became effective on October 1, 2020. 3 This is the American ICD-10-CM version of T81.3 - other international versions of ICD-10 T81.3 may differ.
Use secondary code (s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Codes within the T section that include the external cause do not require an additional external cause code. Type 1 Excludes.
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:
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.).
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.
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.
If a physician only uses adhesive strips to close a wound, the repair must be reported using an E/M code ( 99201 - 99499) instead. The following steps will help you to code for a wound repair:
Coding Excisions. An excision is the surgical removal or resection of a diseased part by an incision through the dermal layer of the skin , and may be performed on either benign or malignant skin lesions.
A 2.5 cm intermediate repair on the right shoulder, a 1.0 cm intermediate repair on the scalp, and a 1.0 cm intermediate repair on the left shoulder would be coded as12032, Wound Repair, Intermediate, 2.6 cm to 7.5 cm.
With some excisions, it may be necessary to report more than one procedure code in order to capture the full services performed. When multiple surgical procedures are performed on the same patient, by the same physician, on the same day, during the same encounter, add modifier 51 (Multiple Procedures) to all subsequent procedures.
All simple wound repairs are included in the surgical package of the excision, and may not be reported separately.
Within each level of repair, wounds are classified according to anatomic location. Note that these categories are not identical for each level of repair. Scalp, neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet) (12001-12007) 3.
Often, the physician repairs several wounds in a single session. When multiple wounds are repaired, check if any repairs of the same classification (simple, intermediate, complex) are grouped to the same anatomic area. If so, per CPT® coding guidelines, the lengths of the wounds repaired should be added together and reported with a single, cumulative code. Do NOT combine wounds of different complexity or those that fall within separate anatomical location groupings.#N#When reporting wounds of differing severity and/or location, claim the most extensive code as the primary service and append modifier 59 Distinct procedural service to subsequent repair codes. Multiple procedure reductions will apply for the second and subsequent procedures, except for those reported using an add-on code.
Wound repair is often performed with other related procedures. Some of these related procedures can be separately reported, while others can’t or depend on specific circumstances. Here’s a breakdown of how to determine when separate reporting is warranted.#N#Never reported separately with wound repair: