Here’s how to strengthen your charting and reimbursement.
For most emergency clinicians, providing high-quality care for our patients with lacerations is built into our DNA. Having a keen proficiency in wound management is just what we were trained to do. However, for many of us, our training did not include learning the skills of how to fully detail our service in this area. In order to get properly paid for our work, we do need to be vigilant here. In 2021, the reality is our careers and longevity in Emergency Medicine relies on our ability to chart effectively. This article will show you how to optimize your reimbursement with laceration repairs.
Not All Lacerations Are Created Equal
It’s true. A number of factors must be considered. Laceration length, wound contamination, foreign body removal, layers of repair and devitalized tissue all come into play. These factors not only influence your treatment approach, but also impact the potential financial return you receive for your service. Don’t overlook the value of your care. Be sure to detail all of your wound care and suture repair interventions in your documentation. Your reimbursement potential is likely greater than you think.
Make Sure You Are Focused
A few starting tips to help optimize reimbursement with your wound repairs:
- Don’t estimate wound lengths. Most clinicians tend to under-estimate laceration lengths. Therefore, measure all of your laceration repairs. Every laceration, every time — you’ll be surprised.
- As above, “always measure” lacerations, but moreover measure after they are repaired. Interestingly, AMA CPT guidelines specify it is the measured repaired wound length that should be reported.
- Finally, documented laceration lengths should be consistent among all providers who are involved in a particular patient’s care. When working with your Advanced Practice Providers and resident physician colleagues, make certain you are all reporting the same lengths.
Additional Caveats with Laceration Repair
There are some important delineation points in laceration repair: 0 – 2.5 cm/2.6 cm to 5.0/5.1 cm to 7.5/7.6 cm to 12.5 cm. Stay vigilant and measure your wound closures appropriately. Keep in mind, when multiple wounds (assuming the same classification category as described below) are repaired within the same anatomical site, wound lengths are added together and assigned one representative CPT code. Your laceration repairs do add up. Lastly, always note these important details: location of the wound, any “extensive cleaning,” removal of particulate matter, debridement of wound edges, undermining of wound edges (“limited” or “extensive”) and simple vs. layered closure.
There is a Difference in the Details
The service you provide and your ability to properly detail that service does make a difference. For example, a single-layer laceration repair of a 2.4 cm leg wound reimburses 1.30 RVUs = $ 45.36, as paid by Medicare. This categorized as a “simple repair,” CPT 12001 simple repair of superficial extremity wound, up to 2.5 cm.
Alternatively, compare this to a multi-layer laceration repair of a 3.4 cm leg wound that also requires debridement of its wound edges. This categorized as a “complex repair,” CPT 13121 complex repair of extremity wound, 2.6 cm to 7.5 cm. This repair reimburses 7.51 RVUs = $ 262.05 as paid by Medicare. These figures are based on the 2021 Medicare Physician Fee Schedule, in which 1 RVU = $ 34.89.
As you can see, the complexity of repair does impact the potential reimbursement for the service you provide. Also recall many private insurers reimburse higher. Here’s the catch — without providing the proper detail in your documentation, your reimbursement is going nowhere. Your ability to chart effectively does impact your bottom-line.
Good to Know – 3 Key Levels of Wound Repair
The following categories are how Emergency Medicine coders “think” to properly code your encounters:
1) “Simple” laceration repair => involves a single layer closure.
2) “Intermediate” laceration repair => involves extensive cleaning, removal of particulate matter, limited undermining and/or a multiple-layered closure.
3) “Complex” laceration repair => typically involves multiple-layered closure and additional interventions including: A) debridement of devitalized wound edges or B) any “extensive undermining.”
These designations of simple, intermediate or complex in laceration repair indeed matter — distinct RVUs (and associated levels of reimbursement) are assigned for each.
The definition of “limited” vs. “extensive” undermining does warrant special mention. “Extensive” undermining is defined as “a distance greater than or equal to the maximum width of the defect, measured perpendicular to the closure line along at least one entire edge of the defect”. Here’s the translation for Emergency clinicians – i.e. your procedure note should look like this: “The 10 cm thigh laceration was examined and had a maximal width of 1.5 cm. The wound’s edges were under considerable tension and extensive undermining was required. Therefore, using a #11 blade, 1.5 cm of undermining was performed along its entire medial wound edge.”
On the flip side, “limited” undermining involves repairs in which there is undermining from the wound’s edge to a distance less than the maximum width of the laceration itself. (i.e. “0.5 cm of undermining was performed” in the example above) My apologies for getting into the coding weeds! In any event, this would qualify your procedure as an “intermediate” repair.
How to Chart (and Reimburse) Optimally with Laceration Repairs:
- “The wound was heavily contaminated by dirt particles and required copious irrigation.” => “intermediate” repair.
- “Using forceps, I removed several wood particles from the wound.” => “intermediate” repair.
- “Lower Leg 8 cm Laceration Multi-layer Repair…the subcutaneous tissue was closed using 4-0 vicryl, six buried horizontal mattress sutures. Next the skin was closed using 4-0 nylon, 16 simple interrupted sutures…” => “intermediate” and potentially “complex” repair.
- “The wound’s lateral edge was devitalized and irregular. Therefore, this edge required debridement and revision using iris scissors.” => “complex” repair, when associated with multi-layered closure.
Stay sharp in your documentation and you can realize the appropriate return for the service you provide. Document better, reimburse better — that is the key for your reimbursement success in Emergency Medicine.
Does the time involved with the wound repair play a role in reimbursement? I’ve heard from other colleagues you need a minimum amount of time to bill for your procedure, but I have yet to find any collaborating information.
Thanks for your question – in non-teaching practices (those not involving resident physicians), the time involved in wound repair does not factor into reimbursement (i.e. laceration repair CPT codes are not timed based). Critical Care and Moderate Sedation CPT codes / services are among the most common time-based services emergency physicians provide in everyday practice.
Your colleagues are likely referring to laceration repair which involve resident physicians. As per ACEP Reimbursement FAQs (updated Feb 2021) => “For minor surgical procedures (lasting less than five minutes), the teaching physician must be physically present during the entire service. For major procedures (lasting more than five minutes), the teaching physician must be physically present during the “key portion(s)” of the service and must be immediately available to furnish service during the entire procedure.” In these situations, time does factor in.
I see that you addressed the limited and extensive undermining, however, I do not see the following address for complex repair: exposure of bone, cartilage, tendon, or named neurovascular structure. If you have more information on this or example documentation, that would be great! I did not see anything via ACEP on this topic.