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Dermatology Coding Alert

Use CPT Guidelines to Help You Decipher Wound Repair

Published on Thu Apr 08, 2004 Print Friendly and PDF PDF

4 guidelines to follow to recoup your deserved pay

Use your CPT book to learn the steps for coding for closures. If your dermatologist completed a lesion excision that required more than a simple repair, you can report the repair in addition to the lesion removal. 
 
CPT defines the three types of repairs:

  • Simple repair is used when the wound is superficial, e.g., involving primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures, and requires simple one-layer closure. This includes local anesthesia and chemical or electrocauterization of wounds not closed.

  • Intermediate repair includes the repair of wounds that, in addition to the above, require layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (nonmuscle) fascia, in addition to the skin (epidermal and dermal) closure. Single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair.

  • Complex repair includes the repair of wounds requiring more than layered closure, viz., scar revision, debridement (e.g., traumatic lacerations or avulsions), extensive undermining, stents or retention sutures.  Necessary preparation includes creation of a defect for repairs (e.g., excision of a scar requiring a complex repair) or the debridement of complicated lacerations or avulsions. Complex repair does not include excision of benign lesions.

    Fortunately, CPT outlines in detail the steps to use for coding wound closures. Instructions for listing services at the time of wound repair, according to CPT, are:

    1. The repaired wound(s) should be measured and recorded in centimeters, whether curved, angular or stellate.

    2. When multiple wounds are repaired, add together the lengths of those in the same classification (see above) and from all anatomic sites that are grouped together into the same code descriptor. For example, add together the lengths of intermediate repairs to the trunk and extremities. Do not add lengths of repairs from different groupings of anatomic sites (e.g., face and extremities).  Also, do not add together lengths of different classifications (e.g., intermediate and complex repairs).

    When more than one classification of wounds is repaired, list the more complicated as the primary procedure and the less complicated as the secondary procedure, using modifier -51 (Multiple procedures).

    3. Decontamination and/or debridement: Debridement is considered a separate procedure only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when debridement is carried out separately without immediate primary closure.

    4. Involvement of nerves, blood vessels and tendons: Report under appropriate system (nervous, cardiovascular, musculoskeletal) for repair of these structures. The repair of these associated wounds is included in the primary procedure unless it qualifies as a complex wound, in which case modifier -51 applies.

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