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I am preparing for the CPC exam and found an article in Becker's that says: "the physician will state a layer closure or intermediate wound repair was performed after the excision. Coders can assign an extra code and generate a different payment if there is a layer closure or intermediate wound repairs, but only closures that apply to subcutaneous tissue can be considered "layer closures." If the physician says he or she performed a layer closure but does not indicate which tissues were closed, the coder should not report the procedure as a layer closure.
In the case of a closure that does not affect the subcutaneous tissue, coders should use the code for a simple repair. "If the physician just says layer closure and doesn't document tissues closed in the body of the op report [and you still code for a layer closure], you're generating money you're not entitled to.
However, a question on my AAPC CPC practice exam contradicted this. The documentation stated a layered closure was performed without mentioning the tissue and the rationale was "According to CPT® guidelines “Repair of an excision of a malignant lesion requiring intermediate or complex closure should be reported separately”. The intermediate repair code is reported because it was a layered closure".
Here is the scenario "A 46-year-old female had a previous biopsy that indicated positive malignant margins anteriorly on the right side of her neck. A 0.5 cm margin was drawn out and a 15 blade scalpel was used for full excision of an 8 cm lesion. Layered closure was performed after the removal. The specimen was sent for permanent histopathologic examination. What are the CPT® code(s) for this procedure?"
Thanks in advance for your help
In the case of a closure that does not affect the subcutaneous tissue, coders should use the code for a simple repair. "If the physician just says layer closure and doesn't document tissues closed in the body of the op report [and you still code for a layer closure], you're generating money you're not entitled to.
However, a question on my AAPC CPC practice exam contradicted this. The documentation stated a layered closure was performed without mentioning the tissue and the rationale was "According to CPT® guidelines “Repair of an excision of a malignant lesion requiring intermediate or complex closure should be reported separately”. The intermediate repair code is reported because it was a layered closure".
Here is the scenario "A 46-year-old female had a previous biopsy that indicated positive malignant margins anteriorly on the right side of her neck. A 0.5 cm margin was drawn out and a 15 blade scalpel was used for full excision of an 8 cm lesion. Layered closure was performed after the removal. The specimen was sent for permanent histopathologic examination. What are the CPT® code(s) for this procedure?"
Thanks in advance for your help