Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-45
Topic: Repair of Lacerations
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

Simple repair of lacerations (12001-12018) includes the repair of superficial wounds involving skin and/or subcutaneous tissues. Layered closure of wounds (12031-12057) involves deeper layers such as fascia or muscle.

Complex repair of lacerations (13100-13153) involves more complicated wound closure, but does not include tissue rearrangement.

Repair of adjacent tissue transfer or rearrangement (14000-14350) includes skin grafts or unusual techniques (e.g., Z-plasty, W-plasty, V-Y plasty, rotation advancement or double pedicle flaps) including the necessary preparation of tissue and/or debridement.

A through-and-through laceration should be based on the site and length reported (codes 12031-12057) and, if necessary, reviewed for payment.

Refer to the multiple surgery guidelines in Medical Policy Bulletin S-100 when multiple lacerations are involved.

Wound closure utilizing only tissue adhesive should be reported with procedure code G0168. Procedure code G0168 should not be billed in addition to another closure code for treatment of the same laceration. If an adhesive is used in combination with another method of closure, e.g., sutures, report only the appropriate closure code.

Procedure Codes

120011200212004120051200612007
120111201312014120151201612017
120181203112032120341203512036
120371204112042120441204512046
120471205112052120531205412055
120561205713100131011310213120
131211312213131131321313313150
131511315213153140001400114020
140211404014041140601406114300
14350G0168    

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

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Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.