Dermatology Coding Alert

Question: Should I rely solely on my doctor's documentation to specifically state "layered closure," or are there other guidelines I can follow to find out if my doctor completed a layered closure?

Virginia Subscriber

Answer: This is where a sound knowledge of anatomy might help you. It is true that a doctor may not always clearly document a "layered closure." However, the doctor should write something to the effect of "Closed fascia with ... and skin with ... suture material."

With documentation such as this, you could conclude that the doctor closed two separate layers -- the fascia, which is the tissue layer beneath the subcutaneous layer, and then the skin, totaling two layers.

-- Answers to You Be the Coder and Reader Questions were reviewed by Linda Martien, CPC, CPC-H, National Healthcare Review in Woodland Hills, Calif; and William J. Conner, MD, at Meridian Medical Group, a multi-specialty practice in Charlotte, N.C.