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Understanding How to Document Lacerations

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 Level 3 (99283): 1.75 RVU Level 4 (99284): 3.32 RVU Level 5 (99285): 4.9 RVU. Lacerations.

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Understanding How to Document Lacerations

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  1. Understanding How to Document Lacerations Larry Halem, MD, CPC VEP Regional Productivity Director

  2. E+M reference guide • Level 1 (99281): 0.6 RVU • Level 2 (99282): 1.17 RVU • Level 3 (99283): 1.75 RVU • Level 4 (99284): 3.32 RVU • Level 5 (99285): 4.9 RVU

  3. 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

  4. 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

  5. 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)

  6. 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

  7. Lacerations • Simple body area 1 • 2.5 cm or less: 1.27 • 2.6-7.5 cm: 1.68 • 7.6-12.5 cm: 2.1 • 12.6-20 cm: 2.73 • 20.1-30 cm: 3.36 • Over 30cm: 4.21

  8. Lacerations • Simple body area 2 • 2.5 cm or less: 1.58 • 2.6-5 cm: 1.66 • 5.1-7.5 cm: 2.14 • 7.6-12.5 cm: 2.7 • 12.6-20 cm: 3.68 • 20.1-30cm: 4.48 • Over 30 cm: 5.07

  9. 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)

  10. 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

  11. Lacerations • Complex lacerations: • Trunk • 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

  12. 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

  13. Tissue Adhesives • Laceration • Repair with tissue adhesive: 0.8

  14. 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

  15. 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

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