As discussed in my article on gunshot wounds, a gunshot wound is a penetrating wound or a puncture wound. It is also a traumatic wound. A stab wound also fits into this category.
According to the documentation provided in this coding challenge, the patient received a penetrating knife wound to the upper abdomen, and wound exploration and repair was performed.
Locate and Verify
To locate the correct CPT code, look in the Index under Wound, exploration 20100-20103. When we go to the Surgery section in the Musculoskeletal System, we can verify the correct code as:
20102, Exploration of penetrating wound (separate procedure); abdomen/flank/back
Wound Exploration codes are found in the Surgery section on the Musculoskeletal System under the General heading and Wound Exploration-Trauma (e.g., Penetrating Gunshot, Stab Wound) (20100-20103) subheading. Codes 20100-20103 are classified by anatomic site, as shown in the table below.
CPT Coding Guidelines
According to the AMA coding guidelines, “20100-20103 relate to wound(s) resulting from penetrating trauma. These codes describe surgical exploration and enlargement of the wound, extension of dissection (to determine penetration), debridement, removal of foreign body(s), ligation or coagulation of minor subcutaneous and/or muscular blood vessel(s), of the subcutaneous tissue, muscle fascia, and/or muscle, not requiring thoracotomy or laparotomy.”
Note: Codes 20100-20103 come from the Musculoskeletal System and are reported when the penetrating wound requires enlargement and no thoracotomy or laparotomy is needed.
The coding guidelines also state, ” If a repair is done to major structure(s) or major blood vessel(s) requiring thoracotomy or laparotomy, then those specific code(s) would supersede the use of codes 20100-20103.”
Note: If the penetrating wound is so severe that organ damage is suspected, a thoracotomy or laparotomy may be necessary to control the bleeding and repair the damage. When this occurs, the code comes from the appropriate anatomic site. For example, a patient with a knife wound to the upper abdomen with suspicion of pancreatic injury requires an exploratory laparotomy. The code would be located in the Digestive System subsection and the subheading Abdomen. In this case, the wound exploration is included in the laparotomy and should not be reported separately.
The coding guidelines further state, “To report simple, intermediate, or complex repair of wound(s) that do not require enlargement of the wound, extension of dissection, etc., as stated above, use specific Repair code(s) in the Integumentary System section.”
Note: These codes are used for repair of wounds that are simple, intermediate, and complex and do not require enlargement. They are found in the Integumentary System section.
B, C, and D are incorrect.
12032 refers to Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm. (B)
12001 refers to Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less. (C)
49000, Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure). (D)
Celiotomy is another term for laparotomy; it is a surgical procedure to open the abdomen. celi/o means abdomen; -tomy means process of cutting.
Well, How Did You Do?
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If you didn’t get it right today, you will. It just takes time and persistence.