# simple, intermediate, or complex?



## Emingoy114

What determines if a repair is simple, intermediate, or complex?


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## Mojo

CPT defines each of the closures in the integumentary system section (before code 12001). Note the use of modifier 51 in the instructions.

Some tips for wound repairs:
Simple repairs involve single layer closure with sutures, staples or skin adhesives (Dermabond). Report G0168 (Wound closure utilizing tissue adhesive only) for Medicare payers. You may see the use of chemical (silver nitrate) or electrocautery. 

Steri-strips alone are not assigned a wound repair code. 

Intermediate repairs include those requiring multi-layered closure or single layer repair that are heavily contaminated. 

If the physician mentions repair to the depth of muscle or deeper, it’s complex. Complex repairs are often reconstructive procedures and include creation of a defect to be repaired (for instance, excision of the scar and subsequent closure). 

Good luck on the exam.


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## AL

Per CPT: 
Simple repair is used when the wound is superficial; eg, involving primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures, and requires simple one layer closure. This includes local anesthesia and chemical or electrocauterization of wounds not closed.

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.

Complex repair includes the repair of wounds requiring more than layered closure, viz., scar revision, debridement (eg, traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. Necessary preparation includes creation of a limited defect for repairs or the debridement of complicated lacerations or avulsions. Complex repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions, excisional preparation of a wound bed (15002-15005) or debridement of an open fracture or open dislocation.


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## DeeCPC

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. 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.  

Dee, CPC,CPCD,CPMA


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## Mojo

DeeCPC said:


> 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.


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## kwitts81

*Coding intermediate repair*



Mojo said:


> 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.


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## CodingKing

kwitts81 said:


> 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.



I believe depth would need to be documented. Looking up one 4-0 Vicryl deep stitch it says its dermal so that would be simple

https://lacerationrepair.com/basic-suturing-techniques/simple-interrupted-dermal-sutures/



> 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.


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## calicoder10

Is a vessel was ligated with figure 8 deep and 5 deep sutures through the muscle then the skin closed with simple interrupted sutures...would this be considered a complex repair ?

Thanks


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## Venkatakrishnan

Hi Emingoy,

Below link from AAPC blog provides you the complete picture of repair.

Thanks,
Vernon Kreiss


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## acf7575

So, I am aware of the CPT instructions for Intermediate repair. "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."

It has been my understanding that  a layered closure was more than one layer, i.e. subcutaneous tissue and skin.  What I find confusing is "one or more deeper layers of subcutaneous tissue and superficial fascia...".  So, would the below example be considered a layered closure, I thought so initially, but now I question myself...

"The wound was then closed with multiple 3-0 Vicryl in a subcuticular 4-0 Monocryl.  Dermabond was applied to the incision."


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