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Laceration Repair Documentation Checklist

Posted on 14. Aug, 2009 by in Toolkit

Sew Up Laceration Repair Coding With These 8 Elements

Unless you want to grapple with denials, the procedure notes that support your physicians’ laceration repair claims should contain these 8 elements. How do the physicians in your practice measure up?

• location

• length

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• layers

• decontamination (including foreign material removed)

• tissue management

• exploration of wound and contiguous structures

• anesthesia technique

• repair of underlying structures.

Example: A good procedure note for a simple scalp repair might read: “After cleansing with betadine, repaired single-layer scalp wound, 8.4 cm, with 14 4-0 prolene sutures under local anesthesia. No foreign material removed; no repair of underlying structures or tissue management required. Wound and surrounding structures...

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