Understanding How to Document Lacerations Larry Halem, MD, CPC VEP Regional Productivity Director
E+M reference guide Level 1 (99281): 0.6 RVU Level 2 (99282): 1.17 RVU
Lacerations Laceration are broken down by location Body Area 1: scalp, neck, axillae, external genitalia, trunk, and extremities Body Area 2: face, ears, eyelids, nose, lips and/or mucous membranes These are the 2 main areas but be specific as this can greatly affect how the laceration codes
Lacerations Lacerations are broken down by complexity of the laceration Simple: single layer closure Intermediate: multiple layer closure that involves simple trimming or debridement Single layer closure requiring extensive cleaning or removal of foreign bodies Complex: Creation of new wound margins with excision of old wound Extensive undermining Scar revision
Lacerations If you have multiple lacerations in the same body area and the same complexity, these lacerations length will be added together Example: Patient has a 3 cm simple laceration to the right hand, a 5 cm simple laceration to the left leg, and a 2 cm simple laceration to the face (total length in body area 1 is 8 cm and total length in body area 2 is 2 cm)
Lacerations Why is this important? For patients with large and multiple lacerations there are upper limits of billing within each area Maximum length that can be billed is over 30 cm per body area However, each body area can be billed up to over 30 cm each for simple, intermediate, and complex Example: Patient has a 32 cm simple closure leg laceration and a 3 cm intermediate closure right arm laceration (Even though they are in the same body area, and we have exceeded 30 cm for the leg, the arm repair will still code because it is a different complexity
Lacerations Simple body area 1 2.5 cm or less: 1.27 2.6-7.5 cm: 1.68 Over 30cm: 4.21
Lacerations Simple body area 2 2.5 cm or less: 1.58 2.6-5 cm: 1.66 Over 30 cm: 5.07
Lacerations Intermediate Body area 1: scalp, axillae, trunk, and extremities ***Hands, feet, neck and genitalia separated () 2.5 cm or less: 4.41 (4.44) 2.6-7.5 cm: 5.62 (5.79) 7.6-12.5 cm: 5.98 (6.19) 12.6-20 cm: 6.91 (7.76) 20.1-30 cm: 8.03 (8.9) Over 30cm: 9.47 (10.64)
Lacerations Intermediate body area 2: face, ears, eyelids, nose, lips and/or mucous membranes 2.5 cm or less: 4.94 2.6-5 cm: 5.89 5.1-7.5 cm: 6.28 7.6-12.5 cm: 6.41 12.6-20 cm: 8.79 20.1-30cm: 9.85 Over 30 cm: 11.28
Lacerations Complex lacerations: Trunk Scalp, extremities 1.1-2.5 cm: 5.9 2.6-7.5 cm: 7.32 each additional 5 cm: 2.15 Scalp, extremities 1.1-2.5 cm: 6.82 2.6-7.5 cm: 7.73 Each additional 5 cm: 2.48
Lacerations Complex lacerations: Forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, feet 1.1-2.5 cm: 7.23 2.6-7.5 cm: 9.11 Each additional 5 cm: 3.81 Eyelids, nose, ear, lips 1.1-2.5 cm: 8.31 2.6-7.5 cm: 10.1 Each additional 5 cm: 4.1
Tissue Adhesives Laceration Repair with tissue adhesive: 0.8
Lip laceration: special considerations If wound is a full thickness injury: through and through Repair of full thickness; vermilion border only: 8.63 Repair lip full thickness; up to half of vertical height: 10.23 Repair of lip, full thickness; over ½ of vertical height or complex: 12.34 Note: superficial laceration of lip even if it involves vermilion 2.5 cm or less: 1.58
Mouth lacerations Vestibule of mouth: area between teeth and lips and cheek 2.5 cm or less: 4.85 Over 2.5 cm : 6.58 Tongue lacerations: 2.5 cm or less: 5.27 Over 2.5 cm: 6.15