General Surgery Coding Alert
Distinguish Simple, Intermediate, Complex Closure
Question: The surgeon repaired an 8.3 cm gash on a patient’s chest. The wound was very deep, involving subcutaneous tissue and superficial fascia in addition to the skin. The surgeon preformed a multiple-layer closure. How should I code this?
Codify Subscriber
Answer:The correct code for this procedure is 12034 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 7.6 cm to 12.5 cm).
Because the wound repair involves multi-layer closure of tissues extending into subcutaneous tissue, you need to use an intermediate repair code. Once you’ve settled on intermediate repair, you select the proper code based location and size of the repair.
Tip: Save the simple repair codes, such as 12004 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 7.6 cm to 12.5 cm), for one-layer closer involving just the dermis and epidermis.
If the wound also required extensive debridement and the surgeon adequately documents the work, you might be able to report an extensive repair code such as 13101 (Repair, complex, trunk; 2.6 cm to 7.5 cm) and +13102 (… each additional 5 cm or less [List separately in addition to code for primary procedure]).
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