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Wiki Dehiscence repair

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simplytam

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I'm interested in opinions on how the following procedure should be coded. This is following a mastectomy and placement of breast implant. I'm not sure if it should be debridement, intermediate or complex repair, 13160? "An ellipse of tissue was sharply removed around and including the open wound. The skin was extremely thin. I did take wider margins around the open area to get into thicker skin, but even here it was quite thin. The underlying implant was protected from trauma during this time. The wound was then irrigated with saline. The resulting incision was closed in layers. It was not closed under tension. The dermis was very thin so I pulled dermis from several mm away from the incision edge to evert the skin. Bacitracin and gauze were applied." Thank you for any help
 
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I would say intermediate repair due to the fact it is removing of particulate matter, and it was a layered closure.

Documentation needs to state, " layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) 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."

And complex must state the above (deeper layers of subcutaneous PLUS, more than layered closure, viz., scar revision, debridement (eg, traumatic lacerations or avulsions), extensive undermining, stents or retention sutures.
CPT does not describe 'extensive' undermining.
 
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