You do not code the lesion size from the path report. The skin shrinks so the lesion size would appear smaller. Eitherway, if they want to get paid then they need to document the work.
Intermediate closures need to be documented as into the deeper subcutaneous, "…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." **your example is not an intermediate closure.
Stating a closure was in layers, intermediate or complex is not enough. Giving two types of suture materials is not enough.
Complex is the above quoted description PLUS scar revision, debridement (eg, traumatic lacerations or avulsions), extensive undermining, stents, or retention sutures. Extensive undermining is not described in the CPT.
PS a simple closure of heavily contaminated wounds that require extensive cleaning or removal of particulate matter also constitutes intermediate repair.
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