Laceration Repair
[Simple / intermediate / complex] laceration repair, [location], [X] cm
Laceration of the [location] [without / with] foreign body, sustained [in a fall / in a motor vehicle collision / in an assault / from [object]].
[[Verbal / Written] informed consent was obtained after discussion of risks, benefits, and alternatives / The procedure was emergent for hemorrhage control, and consent was implied].
[***, MD/DO]
Local: [X] mL [1% lidocaine with epinephrine 1:100,000 / 1% plain lidocaine / 0.25% bupivacaine] [with digital block / field block / wound infiltration]
A [X]-cm [linear / stellate / irregular / bite] laceration of the [location], [actively bleeding / hemostatic] on arrival. Wound depth: [skin only / subcutaneous tissue / fascia / muscle visible]. Wound edges: [clean / crushed / contaminated]. [Foreign body: none identified / [material] removed]. [Distal neurovascular exam: intact / [deficit]]. [Tendon: intact on range of motion testing / [injury]].
[A time-out was completed confirming the patient, procedure, and site.] Local anesthesia was achieved with [X] mL of [1% lidocaine with epinephrine 1:100,000 / 1% plain lidocaine / 0.25% bupivacaine] administered by [wound infiltration / digital block / field block]. Adequate anesthesia was confirmed.
The wound was irrigated with [X] mL of [normal saline / potable tap water] under pressure and explored. [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.]
[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.
Hemostasis was confirmed. The wound was cleaned and dressed with [non-adherent dressing / bacitracin ointment and dry gauze / Steri-Strips].
Minimal
None
None
Wound care instructions were given, and the patient was instructed to keep the wound clean and dry. Suture removal is planned in [3-5 days for face / 7-10 days for scalp, trunk, upper extremity / 10-14 days for lower extremity, hands, over joints]. Tetanus prophylaxis was [up to date / administered]. [[Antibiotic] was prescribed for [X] days.] Return precautions were reviewed.
Epic SmartPhrase Version
PROCEDURE: [Simple / intermediate / complex] laceration repair, ***, *** cm
INDICATION: Laceration of the *** [without / with] foreign body, sustained ***.
CONSENT: [Verbal / Written] consent obtained after discussion of risks, benefits, and alternatives.
PERFORMED BY: ***, MD/DO
ANESTHESIA: Local: *** mL 1% lidocaine [with epi / plain] via [infiltration / digital block]
FINDINGS: *** cm [linear / stellate] laceration of the ***. Depth: ***. Edges: ***. No foreign body. Distal neurovascular exam intact. No tendon injury on ROM.
PROCEDURE DETAILS:
Local anesthesia with *** mL 1% lidocaine [with epi / plain], adequate. Irrigated copiously with [normal saline / tap water] under pressure and explored. [Devitalized tissue debrided sharply.] [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
POST-PROCEDURE PLAN: Wound care instructions given. Sutures out in *** days. Tetanus: ***. Return precautions reviewed.
Signed: .ME, .MYDEGREE
.TODAYVariants
Scalp Laceration (Staples or Galea Repair)
The scalp laceration measured [X] cm. The galea was [intact / lacerated]. [The galea was closed with interrupted [2-0 Vicryl] sutures.] The skin was closed with [staples / interrupted 3-0 Nylon sutures]. Hemostasis was confirmed. [Staple / Suture] removal is planned in 7–10 days.
Facial Laceration (Cosmetic Closure)
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.] Suture removal is planned in 3–5 days.
Hand / Finger Laceration (Digital Block)
A digital block was performed with [X] mL of [1% lidocaine with epinephrine / 1% plain lidocaine / 0.5% bupivacaine] at the [web space / base of the digit]. Adequate anesthesia was confirmed at [X] minutes. Tendon integrity was confirmed by [active range of motion testing against resistance / direct visualization of the intact [flexor / extensor] tendon]. [There was no neurovascular deficit distal to the wound.] The wound was irrigated and closed with interrupted [4-0 / 5-0 Nylon] sutures. Suture removal is planned in [10 / 14] days. [An occupational therapy referral was placed.]
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 along [one edge / both edges], at least the maximum width of the defect, to allow tension-free approximation. The deep layer was closed with buried interrupted [3-0 Vicryl] sutures. The skin was closed with interrupted [4-0 Nylon] sutures with precise edge eversion. Suture removal is planned in 10–14 days.
Charting Tips
- Document wound length in centimeters before closure. Length determines the repair code. '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 the medicolegal baseline. A missed tendon injury discovered later is indefensible without a pre-procedure exam documented.
- For scalp lacerations, closing a lacerated galea controls bleeding and eliminates dead space. Outside the face, staples give cosmetic results equivalent to sutures and are faster to place.
- Epinephrine (1:100,000 to 1:200,000) is safe in digital blocks for patients without pre-existing vascular compromise. For the hand, remove sutures at 10 days on the palmar surface and at 14 days on the dorsum or over joints.
- Document tetanus status. Give Td or Tdap if the last booster was more than 10 years ago for a clean wound or more than 5 years ago for a contaminated wound. Add tetanus immune globulin (250 units IM) for a contaminated wound if the patient has had fewer than 3 lifetime doses. For contaminated wounds, document the antibiotic decision.
- Document irrigation volume, solution, and delivery. Normal saline and potable tap water are equally effective. A 19-gauge angiocatheter on a 35-mL syringe delivers adequate pressure.
- For bite wounds:
- Human bites to the hand should not be primarily closed (high-risk for Eikenella and deep infection; always explore for joint/tendon involvement).
- Dog bites to the face can be primarily closed after thorough debridement and irrigation with acceptable cosmetic and infection outcomes per current systematic reviews.
- Dog bites to the hand or foot and puncture wounds should be left open.
- Cat bites (puncture wounds, Pasteurella risk) are generally left open.
Document rabies risk assessment and public health reporting if required.
Documentation & Reimbursement Considerations
- Primary service: Report Laceration Repair as the primary service when it is the definitive operation performed.
- Repair complexity drives the code, not suture material or number of sutures. Simple repair is a one-layer closure of epidermis and dermis. Intermediate repair is a layered closure of subcutaneous tissue and skin, or a single-layer closure of a heavily contaminated wound. Complex repair requires layered closure plus extensive undermining (at least the maximum width of the defect along one entire edge), exposure of bone, cartilage, tendon, or a named nerve or vessel, debridement of wound edges, or retention sutures or stents. Limited undermining does not make a repair complex.
- 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.
- Repairs of the face, ears, eyelids, nose, lips, and mucous membranes carry higher wRVU than trunk and extremity repairs of the same complexity. Use the facial-location codes when the wound is in these locations.
- Simple debridement performed as part of the repair is included in the laceration repair. Do not separately bill surgical debridement for wound preparation. 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.