Question Intermediate Repair Face/Scalp

[apoland]

Hello,

What documentation is everyone looking for to support intermediate repair on the face/scalp? I recently had a discussion with one of my surgeons and they were questioning the subq repair in the face/scalp given some areas have little/no subq. They often do wide undermining in these areas in addition to the layered closure. How would anyone meet the subq requirement in these areas given that some have little/no subq? If that makes sense. How do we ensure they are documenting correctly to support billing? I appreciate any advise. Thank you, Autumn

 

[sinman0531]

Copied directly out of my CPT book:

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 (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure. It includes limited undermining (defined as a distance less than the maximum width of the defect, measured perpendicular to the closure line, along at least one entire edge of the defect). Single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair.

So in other words, if a physician surgeon documents something like " The skin was closed in two layers deep 4-0 PDS" or "small amount of undermining needed to reduce tension", that should be enough to demonstrate intermediate.

 

[apoland]

Copied directly out of my CPT book:



So in other words, if a physician surgeon documents something like " The skin was closed in two layers deep 4-0 PDS" or "small amount of undermining needed to reduce tension", that should be enough to demonstrate intermediate.

"The skin was closed in two layers" only indicates the skin was closed and doesn't specify the deeper layers of the subq tissue and fascia like the book says, so I'm sure that supports. I can see the undermining piece, which is quite common for the scalp and face given the thinness/lack of extra skin depending on age. Thank you for your response!