Summary & Overview
CPT 12004: Simple Repair of Superficial Wounds, 7.6-12.5 cm
CPT code 12004 is a nationally recognized billing code for the simple repair of superficial wounds ranging from 7.6 cm to 12.5 cm on various body regions, including the scalp, neck, axillae, external genitalia, trunk, and extremities. This procedure is commonly performed in office settings and is essential for effective wound management in both surgical and primary care practices. The code is relevant for a wide range of clinicians, including surgery, family medicine, and dermatology physicians.
Major payers such as Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare provide coverage for services billed under CPT code 12004. The publication offers a comprehensive overview of payer policies, clinical benchmarks, and recent updates affecting reimbursement and coding practices. Readers will gain insights into the clinical context of wound repair, typical sites of service, and the importance of accurate coding for proper documentation and payment.
This summary serves as a resource for understanding the scope and significance of CPT code 12004 in outpatient wound care, highlighting payer coverage and key policy considerations. The information is designed to support healthcare professionals, billing specialists, and policy analysts in navigating the complexities of medical coding and reimbursement for superficial wound repairs.
CPT Code Overview
CPT code 12004 describes the simple repair of superficial wounds measuring 7.6 cm to 12.5 cm on the scalp, neck, axillae, external genitalia, trunk, and/or extremities, including the hands and feet. This procedure is classified under surgery and is typically performed in an office setting (Place of Service 11). The code is used when wounds require closure but do not involve complex repair techniques or deep tissue involvement. Accurate coding ensures appropriate reimbursement and documentation for wound management services provided in outpatient clinical environments.
Clinical & Coding Specifications
Clinical Context
A patient presents to the office with a laceration on the scalp, neck, axillae, external genitalia, trunk, or extremities (including hands and feet) that requires a simple repair. The wound measures between 7.6 cm and 12.5 cm in length. The clinical workflow involves assessment of the wound, cleaning, and performing a simple closure using sutures, staples, or adhesive strips. The procedure is typically performed by a physician specializing in surgery, family medicine, or dermatology. Documentation includes the location, length, and method of repair, as well as any relevant diagnoses such as laceration without foreign body of the scalp or other parts of the head.
Coding Specifications
-
Modifier
51(Multiple Procedures): Used when more than one procedure is performed during the same session. Indicates that12004is one of several procedures. -
Modifier
59(Distinct Procedural Service): Used to indicate that12004is a distinct service from other procedures performed on the same day, often due to different anatomical sites or circumstances.
| Provider Taxonomy Code | Specialty |
|---|---|
208600000X | Surgery Physician |
207Q00000X | Family Medicine Physician |
208D00000X | Dermatology Physician |
Related Diagnoses
-
S01.81XA: Laceration without foreign body of other part of head, initial encounter- Relevant for wounds on the head not specifically covered by other codes; supports the use of
12004for head lacerations.
- Relevant for wounds on the head not specifically covered by other codes; supports the use of
-
S01.111A: Laceration without foreign body of right eyelid and periocular area, initial encounter- Indicates a laceration in the right eyelid/periocular area; may be relevant if the wound is in this region and requires simple repair.
-
S01.112A: Laceration without foreign body of left eyelid and periocular area, initial encounter- Similar to above, but for the left eyelid/periocular area; supports coding for repairs in this anatomical site.
-
S01.01XA: Laceration without foreign body of scalp, initial encounter- Directly relevant for scalp wounds; supports the use of
12004for simple repair of scalp lacerations.
- Directly relevant for scalp wounds; supports the use of
-
S01.02XA: Laceration without foreign body of nose, initial encounter- Indicates a nose laceration; may be relevant if the repair is performed on the nose and fits the criteria for
12004.
- Indicates a nose laceration; may be relevant if the repair is performed on the nose and fits the criteria for
Related CPT Codes
-
12001: Repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities; 2.5 cm or less.- Used for smaller wounds; may be used in conjunction with
12004if multiple wounds of varying sizes are repaired.
- Used for smaller wounds; may be used in conjunction with
-
12002: Repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities; 2.6 cm to 7.5 cm.- Used for wounds slightly smaller than those covered by
12004; often an alternative or used together for multiple wounds.
- Used for wounds slightly smaller than those covered by
-
12011: Repair of superficial wounds of face, ears, eyelids, nose, lips, and/or mucous membranes; 2.5 cm or less.- Used for facial or mucous membrane wounds; not typically used with
12004unless wounds are in different anatomical regions.
- Used for facial or mucous membrane wounds; not typically used with
-
12013: Repair of superficial wounds of face, ears, eyelids, nose, lips, and/or mucous membranes; 2.6 cm to 5.0 cm.- Used for larger facial wounds; may be an alternative or used together with
12004for multiple wounds in different regions.
- Used for larger facial wounds; may be an alternative or used together with
National Reimbursement Benchmarks
For CPT code 12004, the national mean rate for Medicare is $166.79, while the BUCA (average commercial) mean rate is $145.09. This indicates that Medicare's average reimbursement is higher than the commercial average for this procedure. Among individual commercial payers, UnitedHealth Group has the highest mean rate at $194.99, and Aetna has the lowest at $107.13.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Medicare shows the tightest range at $18.00, reflecting more consistent rates nationally. In contrast, UnitedHealth Group exhibits the widest range at $107.00, indicating substantial variability in reimbursement. Cigna and Blue Cross Blue Shield also display broad ranges, while Aetna and BUCA are more moderate.
The table and chart below present the full breakdown of national benchmarks for each payer, including mean rates and percentile values.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.