Laceration Repair

CPT 12032 · 2.46 wRVU · 10-day global
CPT12032
wRVU2.46
Global10-day
ApproachBedside
ComplexityRoutine
Add-on / Variant CPTs
  • 12001 wRVU: 0.82 — Simple repair, scalp/neck/axilla/trunk/genitalia, ≤2.5 cm (0.82 wRVU)
  • 12002 wRVU: 1.11 — Simple repair, scalp/neck/axilla/trunk/genitalia, 2.6–7.5 cm (1.11 wRVU)
  • 12011 wRVU: 1.04 — Simple repair, face/ears/eyelids/nose/lips/mucosa, ≤2.5 cm (1.04 wRVU)
  • 12013 wRVU: 1.19 — Simple repair, face/ears/eyelids/nose/lips/mucosa, 2.6–5.0 cm (1.19 wRVU)
  • 12031 wRVU: 1.95 — Intermediate repair, scalp/axilla/trunk/extremities, ≤2.5 cm (1.95 wRVU)
  • 12034 wRVU: 2.9 — Intermediate repair, scalp/axilla/trunk/extremities, 7.6–12.5 cm (2.90 wRVU)
  • 12051 wRVU: 2.27 — Intermediate repair, face/mucous membranes, ≤2.5 cm (2.27 wRVU)
  • 12052 wRVU: 2.8 — Intermediate repair, face/mucous membranes, 2.6–5.0 cm (2.80 wRVU)
  • 13100 wRVU: 2.93 — Complex repair, trunk, 1.1–2.5 cm (2.93 wRVU)
  • 13101 wRVU: 3.41 — Complex repair, trunk, 2.6–7.5 cm (3.41 wRVU)
  • 13120 wRVU: 3.15 — Complex repair, scalp/arms/legs, 1.1–2.5 cm (3.15 wRVU)
  • 13131 wRVU: 3.64 — Complex repair, face/neck/hands/feet, 1.1–2.5 cm (3.64 wRVU)
  • 13132 wRVU: 4.66 — Complex repair, face/neck/hands/feet, 2.6–7.5 cm (4.66 wRVU)
  • 13151 wRVU: 4.23 — Complex repair, eyelids/nose/ears/lips, 1.1–2.5 cm (4.23 wRVU)
Preoperative Diagnosis:

[Laceration / wound], [location], [X] cm, [simple / intermediate / complex]

Postoperative Diagnosis:

Same

Procedure Performed:

[Simple / intermediate / complex] laceration repair, [location], [X] cm

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Nurse/tech name]

Anesthesia:

Local: [X] mL [1% lidocaine with epinephrine 1:100,000 / 1% plain lidocaine / 0.25% bupivacaine] [with digital block / field block / wound infiltration]

Indications:

The patient is a [age]-year-old [male/female] presenting with a [X]-cm laceration to the [location] sustained [mechanism: fall / MVC / assault / laceration with (object)]. The wound was [actively bleeding / hemostatic on arrival]. [Neurovascular status distal to the wound: intact.] [Tendon/bone involvement: none identified on exam.] Risks, benefits, and alternatives were discussed and consent was obtained [/ consent waived, emergent hemorrhage control].

Findings:

A [X]-cm [linear / stellate / irregular / bite] laceration at the [location]. Wound depth: [skin only / subcutaneous tissue / fascia / muscle visible]. Wound edges: [clean / crushed / contaminated]. [Foreign body: none identified / [material] removed]. [Neurovascular exam distal: intact / (deficit described)]. [Tendon: intact on range of motion testing / (injury)].

Description of Procedure:

The wound was examined and measured: [X] cm in length. The wound was irrigated with [X] mL of normal saline under pressure. [Foreign material was removed with forceps and irrigation.] [Devitalized tissue was debrided sharply with a [15-blade scalpel / iris scissors] until healthy tissue margins were achieved.]

Local anesthesia was achieved with [X] mL of [1% lidocaine with epinephrine 1:100,000] administered by [wound infiltration / digital block / field block]. Adequate anesthesia was confirmed.

[LAYERED CLOSURE:] The deep layer was closed with interrupted [3-0 / 4-0 Vicryl / Monocryl] sutures approximating the [subcutaneous tissue / dermis]. The skin was closed with [interrupted / simple running] [3-0 / 4-0 / 5-0 Nylon / Prolene / Monocryl] sutures. Wound edges were well-approximated without tension, blanching, or inversion.

[SIMPLE CLOSURE:] The skin was closed with [interrupted / simple running] [3-0 / 4-0 / 5-0 Nylon / Prolene] sutures.

Hemostasis was confirmed. The wound was cleaned and dressed with [non-adherent dressing / bacitracin ointment and dry gauze / Steri-Strips].

Complications:

None

Specimens:

None [/ wound culture sent]

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

The wound was well-approximated. The patient was given wound care instructions and instructed to keep the wound clean and dry. Suture removal was planned in [5–7 / 7–10 / 10–14] days depending on location. Tetanus prophylaxis was [up to date / administered]. [Antibiotics were / were not prescribed.] Return precautions were reviewed.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: *** laceration, [location], *** cm
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Simple / intermediate / complex] laceration repair, [location], *** cm
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Local: *** mL 1% lidocaine [with epi / plain] via [infiltration / digital block]

INDICATIONS: .PTAGE-year-old .PTSEX with *** cm laceration to *** from ***. Neurovascular exam distal: intact. No tendon injury on ROM. Consent obtained.

FINDINGS: *** cm [linear / stellate] laceration at ***. Depth: ***. Edges: ***. No foreign body. No tendon/bone involvement.

PROCEDURE:
Wound measured *** cm. Irrigated copiously with normal saline under pressure. [Devitalized tissue debrided sharply.] Local anesthesia with *** mL 1% lidocaine [with epi], adequate. [Deep layer: interrupted 3-0 Vicryl approximating subcutaneous tissue/dermis.] Skin closed with [interrupted / running] [4-0 Nylon / Prolene / Monocryl], well-approximated, no tension. Hemostasis confirmed. Wound dressed with ***.

EBL: Minimal
SPECIMENS: None
COMPLICATIONS: None
DISPOSITION: Wound care instructions given. Sutures out in *** days. Tetanus: ***. Return precautions reviewed.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Scalp Laceration (Staples or Galea Repair)

The scalp laceration measured [X] cm. The galea was [intact / lacerated]. [Galea repair: The galea was closed with interrupted [2-0 Vicryl] sutures to eliminate dead space and achieve hemostasis, galea closure is the key hemostatic layer in scalp lacerations.] The skin was closed with [staples / interrupted 3-0 Nylon]. [Staples are appropriate for scalp lacerations not involving the face, equivalent cosmetic outcome with faster placement.] Hemostasis was confirmed. Staple/suture removal in 7–10 days.

Facial Laceration (Cosmetic Closure)

Given the facial location, meticulous closure was performed. The deep dermal layer was approximated with buried interrupted [5-0 Monocryl] sutures to eliminate dead space and reduce surface tension. The skin was closed with interrupted [6-0 / 5-0 Nylon / Prolene] sutures with precise edge eversion. [Steri-Strips were applied for additional support.] The patient was counseled on sun protection, scar maturation over 12 months, and availability of scar revision if needed. Suture removal in 5–7 days to minimize track marks.

Hand / Finger Laceration (Digital Block)

A digital block was performed with [X] mL of [1% plain lidocaine / 0.5% bupivacaine] at the [web space / base of digit], epinephrine avoided in digital blocks. Adequate anesthesia was confirmed at [X] minutes. Tendon integrity was confirmed by [active range of motion testing against resistance / direct visualization of flexor/extensor tendon, intact]. [No neurovascular deficit distal to wound.] Wound was irrigated and closed with [4-0 / 5-0 Nylon] interrupted sutures. Suture removal in 10–12 days. [Occupational therapy referral placed for hand wounds involving tendon/joint.]

Complex Repair with Undermining

Given the wound complexity [stellate configuration / tissue loss / wound under significant tension], complex repair was performed. The wound edges were undermined with [scissors / 15-blade] in the [subcutaneous / subdermal] plane for [X] cm circumferentially to allow tension-free approximation. [Retention sutures of 0-Nylon were placed through the full thickness of the dermis to distribute tension.] The deep layer was closed with buried [3-0 Vicryl] interrupted sutures. The skin was closed with [4-0 Nylon] interrupted sutures with precise edge eversion. Suture removal in 10–14 days.

Charting Tips
  • Document wound length in centimeters before closure, this directly determines CPT code selection. 'Small laceration' is not sufficient. If multiple wounds, document each individually and note which are summed for billing.
  • Document closure complexity explicitly: 'layered closure with subcutaneous Vicryl and skin Nylon' supports intermediate repair billing. 'Single-layer skin closure' supports simple repair. The technique described must match the code billed.
  • Document neurovascular exam distal to the wound and tendon integrity before anesthesia is administered, this is a medicolegal baseline. A missed tendon injury discovered later is indefensible without a pre-procedure exam documented.
  • Document tetanus status and prophylaxis given. For contaminated wounds, document antibiotic decision (given vs. not given and reasoning). Document wound irrigation volume and method. 'Copious irrigation' is not sufficient. Target at least 250-500 mL for clean lacerations and 1 L or more for contaminated wounds, delivered under pressure. Document the volume used.
  • For bite wounds (human or animal), document the wound was left open or closed and your reasoning, human bites to the hand should not be primarily closed. Document rabies risk assessment for animal bites and public health reporting if required.
Billing Tips
  • Repair complexity drives code, not suture material or number of sutures. Simple (12001-12018): one-layer closure of epidermis/dermis. Intermediate (12031-12057): layered closure of subcutaneous tissue + skin, OR heavily contaminated wound requiring single-layer closure. Complex (13100-13153): requires undermining, retention sutures, or extensive debridement beyond simple debridement.
  • Location and length determine the specific code within each complexity tier. Measure wound length before closure. Multiple wounds of the same complexity and anatomic region are added together for a single code. Wounds of different complexity or different anatomic region are coded separately.
  • Face/ears/eyelids/nose/lips/mucosa codes (12011-12018, 12051-12057, 13131-13133, 13151-13153) command higher wRVU than trunk/extremity equivalents, use them when the wound is in these locations.
  • Simple debridement performed as part of the repair is included in the laceration repair CPT. Do not separately bill 11042-11047 for debridement that is part of the wound prep. Debridement is separately billable only when it is a distinct, separately identifiable service.
  • 10-day global period (intermediate and complex): wound checks within 10 days are bundled. Suture removal by the operating surgeon is bundled. Suture removal by a different provider generates a separate E/M.
  • If anesthesia (digital block, field block) is administered by the same surgeon performing the repair, it is not separately billable. It is included in the procedural fee.

ⓘ General Billing Tips →