# Simple repair or intermediate repair



## ishtiyaq.ahmad (Jun 8, 2017)

Hi,

Physician is making an incision and goes deeper layer of skin and after excising the scapular cyst he just closed the subcutaneous tissue with sutures and then skin with vicryl sutures.

In this physician is only doing incision to the deeper layer but the closure documentation states only closure of subcutaneous tissue and skin, not a layered closure I believe.

Please suggest that if it is simple closure or intermediate closure.

As per CPT definition: For Intermediate closure there should be documentation of deeper layer of subcutaneous tissue closure and then skin closure. But in the above documentation only incision is deeper but suggest if we can assume that physician is closing the wound with layers or we need to code it as simple repair. 


I just want to know whether we need to see the incision documentation or closure documentation to code the multi layer closure or intermediate closure.


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## ellzeycoding (Jun 8, 2017)

Intermediate repair requires *layered* closure of one or more deeper layers of the skin.  

Documentation is key and needs to mention that superficial fascia or layered closure was required and the medical necessity of this type of repair.

Outside of this, then it would be a simple repair.


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## tjackson1960 (Jul 26, 2017)

*Follow-up question on this topic...*

Based on the given example but with the following differences:  wounds were closed in layers for subcutaneous tissue one way and the skin another.  Also, the depth of the lesion was excised to the chest wall (post-mastectomy scar).  The pathology report also shows the lesion size and reflects deep dermis and subcut in their report.  Is this sufficient documentation to code an intermediate closure even though the superficial (non-muscle) fascia is not specifically documented in the closure statement?  Thanks for any input.  

Smart tips for 12032 states:  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. Single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair.

Surgeon documentation reflects:
Lesion (in skin of post-mastectomy scar) was excised in an elliptical incision down to the chest wall.  Bleeders were controlled with cautery.  The specimen was sent to Pathology.  The wounds were closed in layers with absorbable suture for subcutaneous tissue and clips for the skin.  

Pathology report reflects:
 A.  Specimen is labeled "right chest wall nodule" and consists of an elliptical portion of skin, measuring 3.0 x 1.1 cm and excised to a depth 
     of 1.5 cm, with tan-white epidermis and no grossly discernible lesion.  Surface of specimen is inked entirely black.  Tips are amputated and 
     submitted in cassette A1.  The remainder of the specimen is serially cross sectioned into four pieces, revealing a dermal nodule measuring 1.1 
     cm in diameter.  Four pieces are submitted entirely in cassettes A2 and A3.

      DIAGNOSIS:

         A.  Right chest wall nodule, elliptical excisional biopsy:
             -  Poorly differentiated malignant neoplasm, 
                  morphologically consistent with recurrent breast 
                  carcinoma, involving the deep dermis and subcutis, 
                  focally extending very close to one inked lateral
                  edge of tissue and extending into one inked tip
                  of the specimen


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