CPT Codes for Laceration Repair
Laceration
Simple/Superficial-Scalp, Neck, Axillae, External Genitalia, Trunk, Extremities : 2.5 cm or less – cpt 12001
Simple Repairs
CPT Codes 12001 – 12018
** Usually included in all minor and major Usually included in all minor and major surgical procedures
** Cannot be reported separately when performed in conjunction with minor/major procedure
** However, can be reported if that is the only service provided e.g. simple closure of laceration
Intermediate Repairs (12001 – 12057)
Use for repair of wounds or defects which:
** Require layered closure, one/more deeper layers SC tissue & superficial (nonmuscle) fascia
** Need prolonged support y g (sum of lengths)
Need obliteration of “dead” space
Need prolonged support
Guidelines:
** Code by site and length
** Report in addition to excision code
Note: Not appropriate to be
** used with excision of benign to control tension
** used with excision of benign lesions 0.5 cm or less (11400, 11420, 11440) for Medicare & Aetna
Surgical Team
Under some circumstances highly complex procedures are carried out under the “surgical team” concept. Each participating physician would report the basic procedure with the addition of modifier -66.
Starred Surgical (*) Procedures
Certain services listed in the schedule are marked with a star (*) after the CPT® code.
These are relatively small surgical procedures for which the usual global package does not apply. Payment for the starred (*) service includes anesthesia for infiltration, digital block, or topical application.
When the starred (*) service is performed at the time of the initial visit, and theservice is the major service rendered during the visit, an office visit will be paid when billed with CPT® code 99025. Example: procedure code 12001 (repair of laceration) and procedure code 99025 (initial new patient exam) would both be paid.
When the starred (*) service is performed at the time of an initial or other visit involving significant identifiable service(s), the appropriate E/M service is listed in addition to the starred (*) service. Example: when an initial consult is performed and a joint injection is also performed, it is appropriate to bill and be paid for both the consult and the injection.
When a starred (*) service is performed at the time of a follow-up visit and the surgical procedure constitutes the major service, the evaluation and management service is not paid in addition to the surgical procedure. When the starred (*) service requires hospitalization, an appropriate hospital visit is listed, in addition to the starred (*) surgical procedure and its follow-up care.
Note: When follow-up days are listed as “0” the follow-up services shall be billed as independent procedures.
Note: When billing starred (*) surgical procedures for injection codes into bursa, joints, etc., the Injectable medications may be billed separately using 99070 or the appropriate J code listed in Medicare’s Level II codes. The drug shall be reimbursed at AWP.
HELPFUL CODING HINTS
As part of Oxford’s ongoing effort to provide the best service possible to all providers, Oxford periodically reviews claims data to identify issues that can delay processing. This article is the second in a series of updates that will be featured in this publication on a regular basis. One of the areas frequently noted to cause difficulty is the inappropriate use of repair CPT codes in the ranges of 12001 through 13160 (Repair; simple, intermediate, complex). These codes cannot be billed for more than a quantity of one per each group of anatomic site and classification, and are frequently billed incorrectly with multiple quantities (e.g., 12001 quantity 2.) To ensure timely and correct reimbursement, physicians, when repairing multiple wounds, should total the sums of the lengths of the repairs performed in each anatomic site and bill with the appropriate corresponding repair code.
According to the AMA CPT 2001 description, “when multiple wounds are repaired, add together the lengths of those in the same classification and from all anatomic sites that are grouped together into the same code descriptor.” The following example illustrates this rule: The physician performs a simple repair 1 cm in length on the trunk and a simple repair 1.5 cm in length on the arm. The provider should bill CPT code 12001 with a quantity of one, since the total length of the repairs is equal to 2.5 cm. The AMA CPT 2001 description for code 12001 is “simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less.”
Providers should not add lengths of repairs from different groupings of anatomic sites (e.g., ears and legs) and should not add together lengths of different classifications (e.g., simple and complex repairs). Please remember to add the total lengths of repairs for each group of anatomic sites. The codes within the same classification and anatomic site cannot be billed in multiple quantities.
HCPC Code 12001
To calculate the Division MAR for procedure code 12001 (Repair superficial wounds) in a nonfacility setting using the data provided by CMS:
Step 1. Access the Medicare Physician Fee Schedule Look-up on the CMS website at www.cms.hhs.gov.
Step 2. To find the RVU for the procedure: Provide your search criteria selecting the year, “Single HCPCS Code” and “Relative
Value Units.” To find the GPCI: Provide your search criteria selecting the year, “Single HCPCS Code” and “Geographic Practice Cost Index (GPCI).”
Step 3. To find the RVU for the procedure: On the next page, select “Default Fields.” To find the GPCI: On the next page, select “Specific Locality” and “Default Fields.”
Step 4.
To find the RVU for the procedure:
Continue the process by providing the HCPCS (for this example we are using 12001 Repair superficial wounds in a non-facility setting), and select the appropriate modifier if applicable.
To find the GPCIs for the procedure: Continue the process by selecting the “Carrier Locality” (for this example we are selecting “Rest of Texas”).
Step 5.
To find the RVU for the procedure: Submit your search criteria to find the RVUs for the procedure.
To find the GPCIs for the procedure: Submit your search criteria to find the GPCIs for the locality.
Step 6. Proceed with the calculations. [(Work RVU x Work GPCI)
+ (PE RVU x PE GPCI)
+ (MP RVU x MP GPCI)]
x Division Conversion Factor
= Division MAR
The MAR for CPT code 12001 (Repair superficial wounds) in a non-facility setting provided for the “Rest of Texas” in 2009 is $184.66.
To calculate the Division MAR for procedure code 12001 (Repair superficial wounds) in a facility setting, follow the steps above using the Facility RVUs in place of the Non-facility RVUs.
To calculate the Division MAR for procedure code 12001 (Repair superficial wounds) in a nonfacility setting using the Trailblazer website:
Step 1. Go to the TrailBlazer Health Enterprises, LLC website at www.TrailBlazerhealth.com.
Step 2. If you have already registered on this site, sign in. If you have not, you must register to use the site. There is no cost to use this website.
Step 3. Use the Search function on the Homepage to search for ‘Fee Schedules’ and locate the Medicare Fee Schedule.
Step 4. Select the year of the fee schedule you want (2009), your state (Texas), and yourlocality (Rest of Texas) in the appropriate windows.
Step 5. Enter the procedure code (CPT) (and modifier if applicable) about which you seek information.
Step 6. Find the Medicare CF and divide it into the Division CF (2009 CF – $53.68) to derive the Division multiplier.
Step 7. Find the non-facility Participating Amount and multiply the amount by the Division ratio.