Wiki Complex closure

[AN2114]

I would like a little advice about this report for complex closure. Based on what I've read online, I'm not sure if this is enough of info to report complex closure. So I just want to make sure I code this right. The doctor goes into detail of the procedure for the excision, but when he does the closure, the only thing said is "at this point a complex closure was performed. The deep muscle and subcutaneous layers were closed with 4-0 Vicryl. The skin was closed with running 5-0 Monocryl in a subcuticular fashion." I have the whole report listed below as well.

Name of Procedure:
1. Excision of midline mass on forehead
2. Complex triple layer closure

Procedure: Patient was brought to the operating room and laid supine on the operating table. General anesthesia was induced by the anesthesia team using an LMA. Patient was prepped and draped in the usual sterile fashion. The patient's forehead mass was marked out. A 1cm incision horizontal across the mass was marked. This was injected with half the cc of 1% lidocaine with 1-1 2000 epinephrine. An incision was made through the skin, subcutaneous tissue, to the level of the corrugator muscles. A mixture of blunt and sharp dissection was used to dissect through the corrugator muscles. The forehead mass was noted to be about 1 cm x 1 cm in size. Blunt and sharp dissection was used to remove the entirety of the forehead mass. The forehead mass appeared to be a dermoid cyst. Care was taken to not violate the capsule of the mass. The entire mass was removed. There was a stalk at the base of the mass which was cauterized with Bovie cauter. Hemostasis achieved with bovie cautery. At this point a complex closure was performed. The deep muscle and subcutaneous layers were closed with 4-0 Vicryl. The skin was closed with running 5-0 Monocryl in a subcuticular fashion. Dermabond and steri-strips applied. Patient was awoken from anesthesia and sent to recovery room in stable condition.

 

[Orthocoderpgu]

Understand that coders and physicians use the same words differently. For example, physicians in the hospital get asked all the time to see patients and physicians call it a "Consultation". To them it is, but it does not meet the requirements in the AMA's CPT book to bill a consultation code. Your physician has identified this as a "complex closure", and to them it meets their own definition. True complex closure as defined in the CPT book is "more than layered closure" and usually involves retention sutures and significant undermining. There is nothing documented here that would indicate that complex closure was performed.

 

[csperoni]

I would just add that while this does not seem to meet the coding definition of complex closure, it does seem to be intermediate closure, which is reportable separately from the benign excision.

I also recommend to query the provider about the size. "About 1cm x 1cm" is a bit vague. 1.0cm is one code; 1.1cm is a different code. This is both for the excision and the intermediate closure, so exact measurements are always important. Your provider should be educated about that.

 

[AN2114]

Understand that coders and physicians use the same words differently. For example, physicians in the hospital get asked all the time to see patients and physicians call it a "Consultation". To them it is, but it does not meet the requirements in the AMA's CPT book to bill a consultation code. Your physician has identified this as a "complex closure", and to them it meets their own definition. True complex closure as defined in the CPT book is "more than layered closure" and usually involves retention sutures and significant undermining. There is nothing documented here that would indicate that complex closure was performed.

Thank you!

 

[AN2114]

I would just add that while this does not seem to meet the coding definition of complex closure, it does seem to be intermediate closure, which is reportable separately from the benign excision.

I also recommend to query the provider about the size. "About 1cm x 1cm" is a bit vague. 1.0cm is one code; 1.1cm is a different code. This is both for the excision and the intermediate closure, so exact measurements are always important. Your provider should be educated about that.

Thank you!