Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Laceration size outside 7.6-12.5cm range for this code
Common12004 for simple repairs 7.6-12.5cm. Smaller lacs use lower codes (12001/12002/12005 depending on size). Larger lacs >12.5cm use 12005-12007. Payers strictly enforce size ranges - documentation must match code range.
Common Causes
- • Lac 6.8cm documented - should be 12002 (2.6-7.5cm range), not 12004
- • Lac 13.2cm - should be 12005 (12.6-20cm), not 12004
- • Confusion between 12004 (7.6-12.5cm) and 12005 (12.6-20cm) - overlapping perception
Resolution Strategy
Verify documented size matches code: 7.6-12.5cm = 12004. If size 7.5cm or less, use 12002. If 12.6-20cm, use 12005. Document: 'Linear laceration right thigh measuring 10.2cm in length repaired with simple interrupted 3-0 nylon sutures, 8 sutures placed.' Cannot appeal if size clearly outside code range - must rebill with size-appropriate code.
Relative Value Units (RVUs)
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Clinical Information
When to Use
For simple, single-layer closure of superficial wounds between 7.6 cm and 12.5 cm in length
Common Scenarios
Documentation Requirements
- Precise total wound length
- Anatomic location details
- Suture type and quantity
- Wound preparation and irrigation
- Closure method documented
Coding Guidelines
Common Modifiers
Bundling Rules
- Sum all simple repair lengths in same anatomic grouping
- Includes local anesthesia and simple wound prep
- Simple hemostasis included
Exclusions
- Deep or layered closures require intermediate codes 12031-12057
- Repairs with extensive debridement use appropriate debridement codes separately
Coding Notes
Clinical scenarios
- Precise total wound length
- Anatomic location details
- Suture type and quantity
- Precise total wound length
- Anatomic location details
- Suture type and quantity
- Precise total wound length
- Anatomic location details
- Suture type and quantity
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Code Details
Medicare Pricing
PFSRVU Breakdown
OPPS Details
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Ask a QuestionFrequently Asked Questions
CPT 12004 is the billing code for "Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm". For simple, single-layer closure of superficial wounds between 7.6 cm and 12.5 cm in length
Medicare pays approximately $129.06 for CPT 12004 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 12004 has a total RVU of 4.93, broken down as: Work RVU 2.23, Practice Expense RVU 2.48, and Malpractice RVU 0.22. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 12004 is "Laceration size outside 7.6-12.5cm range for this code". 12004 for simple repairs 7.6-12.5cm. Smaller lacs use lower codes (12001/12002/12005 depending on size). Larger lacs >12.5cm use 12005-12007. Payers strictly enforce size ranges - documentation must match code range. Common causes include: Lac 6.8cm documented - should be 12002 (2.6-7.5cm range), not 12004; Lac 13.2cm - should be 12005 (12.6-20cm), not 12004. Appeal success rate is approximately 10-30%.
Key documentation requirements for CPT 12004 include: Precise total wound length; Anatomic location details; Suture type and quantity; Wound preparation and irrigation. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 12004: Sum all simple repair lengths in same anatomic grouping. Includes local anesthesia and simple wound prep Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 12004 include: 51 (Multiple distinct procedures), 59 (Separate procedural service), 76 (Repeat procedure by same physician). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 12004 is 20-25 minutes typical procedure time. Time-based codes require documentation of the actual time spent providing the service.