Emingoy114
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What determines if a repair is simple, intermediate, or complex?
Documentation of 'layered closure' is not enough to code an intermediate repair.
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.
Dee, CPC,CPCD,CPMA
Absolutely, Dee. I posted the tip as a suggestion that when a coder sees "multi-layer" it may be a heads-up to an intermediate repair if the documentation supports it. A sutured dermal layer followed by Dermabond or sutures through the epidermis would still be a simple repair.
Just curious, our MD's always document like this:
Wound was closed with one 4-0 Vicryl deep stitch and four 4-0 nylon simple interrupted superficial stitches.*
Would you code that as intermediate repair, it was an excision of a cyst.
Simple interrupted dermal sutures (more commonly referred to as deep dermal sutures) are sutures placed within the dermal layer to reduce the static tension on a gaping wound with poor edge apposition.