This 24-year-old male locked himself out of his house. He attempted to punch out a window in his garage door with his elbow and sustained right arm lacerations. His only complaint is multiple lacerations of the forearm, no shoulder pain and no wrist pain. Over the area of the olecranon there is a 3 cm superficial laceration. 

There are also noted to be several simple lacerations distally: approximately four measuring 1 cm each and three others measuring 2 cm each. There is noted to be a 5 cm laceration involving deeper layers of skin. Each wound was vigorously irrigated and draped individually. All wounds were closed with simple sutures except the 5 cm laceration, which required intermediate repair. The patient tolerated the procedure well. 

Code(s): __________

 

The CPT Codes for the case are

• 12005 (It should be reported with the modifier 59) (12005 -59)
• 12032

Modifier of 59 is also added for the case.

Step-by-step explanation

• According to the CPT regulations, if a patient has multiple wounds, the length of the wounds should be combined (Added) together to get the correct code for the wound.
• In this case it would be = 3 + (4 x 1) + ( 3 x 2) = 3 + 4 + 6 = 13 cm (length of the wound)
• According to this length, the CTP code would be 12005 because it refers to the repair of wounds (simple) that are superficial and are present in regions of trunk, genitalia, neck, scalp, axilla that also includes wounds in the arm and feet and the length of the wound should be between 12.6 cm to 20.0 cm.
• CPT code 12032 is used because it is used to refer to the repair of wounds (intermediate) that are present in the neck, scalp, trunk, axilla and does not include hand and extremities. For this code to the reported, the intermediate wound should be between 2.6 cm to 7.5 cm and in this case, it is 5 cm.
• The modifier is used because the case contains more than one type of wound repair and the modifier must be added along with the less complicated wound (secondary procedure). The primary procedure that accounts for the repair of the most complicated procedure is the repair of the intermediate wound.