For the last year or so, health and wellness information management (HIM) specialists have actually been challenged by the must identify a correct code assignment for tissue glue approach (Dermabond). In a recent concern of CPT™ Assistant (May 1999), the Amerideserve to Medical Association (AMA) clarified some of the confusion and explained how open wounds are closed utilizing tproblem glue method.
The a lot of common tworry glue is Dermabond–an adhesive used rather of sutures or staples. The advantage of this technique is that patients perform not must go back to the doctor for removal of the sutures or staples. (Note that adhesive strips, such as butterflies or steri-strips, are not considered adhesive glue approach and must not be reported as such.)
In the 1999 CPT code hands-on, no code descriptions exist for wound repair (straightforward, intermediate, complex) making use of adhesive glue strategy. Tbelow is, but, a CPT code provided for reporting tworry glue strategy as soon as repairing wounds of the cornea and/or sclera. If you are coding this procedure and also tproblem glue method was offered, assign CPT code 65286 (repair of laceration; application of tconcern glue, wounds of cornea or sclera).
The December 1998 CPT Assistant contained a question from a reader regarding tworry glue strategy and also wounds closed by staples. Since the CPT coding hands-on does not have actually a certain coding summary for these techniques, the AMA recommended that code 17999 (unlisted procedure, skin, mucous membrane and subcutaneous tissue) be supplied.
However before, the AMA rescinded this advice in the May 1999 CPT Assistant. For solutions delivered in May 1999 and after, directed the AMA, assign codes from the wound repair area to designate closure utilizing tproblem glue technique. The AMA has actually promised that changes will be made to the CPT 2000 coding hands-on to reflect the usage of tproblem glue method in wound repair.
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Back to Basics
Regardless of all the confusion, though, be sure to adhere to the CPT coding guidelines for simple, intermediate and also complex wound repair before assigning a CPT code for an encounter. Also remember the following meanings of these wound repairs, which deserve to be uncovered in the CPT hand-operated.
* Simple Wound Repair. This superficial wound requires mostly epidermis or dermis, or subcutaneous tproblems without substantial involvement of deeper structures; it needs straightforward, one layer closure/suturing. Typically, this code would be assigned once tproblem glue technique is used to cshed a superficial wound.
* Intermediate Wound Repair. In addition to the above, this repair requires layered clocertain of one or more of the deeper layers of subcutaneous tissue and superficial (nonmuscle) fascia, in enhancement to the skin (epidermal and dermal) closure. Single-layer clocertain of greatly contaminated wounds that have actually compelled comprehensive cleaning or removal of particulate issue additionally constitute intermediate repair.
Coding Tip: Just bereason a doctor says that he or she provides two forms of suture product (absorbable and nonabsorbable) does not show performance of an intermediate repair. In the documentation, the medical professional have to state that the wound was closed in layers.
* Complex Wound Repair. This repair of wounds calls for even more layered clocertain (sauto revision, debridement, traumatic lacerations or avulsions, substantial undermining, stents or retention sutures). It may incorporate defect development and also important repair preparations or debridement and repair of complicated lacerations or avulsions.
In enhancement to following the CPT hand-operated guidelines, documentation additionally is essential to appropriate CPT code assignment. Make certain medical professionals explain the wound repair strategy (e.g., tworry glue method, simple, layer, and so on.) and the size of wound clocertain. If this crucial clinical indevelopment is not contained, ask the doctor around it before assigning a CPT code for wound repair.
The emergency room enrespond to presented listed below mirrors exactly how tissue glue technique might be offered and exactly how to assign a code for it.
Subjective: A six-year-old female dropped off her bicycle and also injured her chin. This did not render her unmindful. She has no neck pain. She did abrade her left elbow.
Objective: Head, eyes, ears, nose and also throat: Pupils are equal, round, continuous and also reenergetic to light and also accommodation. Tbelow is a 3.1 cm, star-shaped, jagged, contaminated laceration existing on the chin. The following are nontender: mandible, temporomandibular joints, neck and chest. Breath sounds: equal. Cardiac: no S3, S4 or murmurs. Abdomen: soft and non-tender. Extremities: some left elbow abrasions however no bony tenderness to indicate fracture. Patient has actually excellent array of motions. No distal neurovascular deficit.
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Assessment: Chin laceration
Treatment: Lidocaine local was provided, and also the wound was debrided and also revised for satismanufacturing facility clocertain. Dermabond was used to approximate the wound edges. The parents were instructed in wound care and advised to return if any kind of indications of infections end up being evident. The patient is given an prompt dose of antibiotic and also some Phenergan with Codeine for the pain from the debridement. Will be inserted on antibiotic for the next few days.
Code Assignment and Rationale
12013 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm
Referring back to the AMA’s clarification (CPT Assistant, May 1999), assign the over code for the wound clocertain using tconcern glue method. *
Susan Howe is a senior health treatment consultant with Medical Learning Inc., St. Paul, MN.