General Surgery Coding Alert

Question: A patient presented with a deep, ragged, debris-filled wound on her abdomen from falling onto a decaying fence with rusty metal parts. The surgeon’s report documents a 7.0 cm layered closure “with extensive undermining.” Is this enough to bill a complex repair?

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Answer: Yes, based on what you describe the appropriate code would be 13101 (Repair, complex, trunk; 2.6 cm to 7.5 cm). The layered closure coupled with documented “extensive undermining” justifies selecting a complex repair code instead of intermediate repair.

Better: However, the surgeon’s documentation could improve, and would help you justify your code choice. For instance, you stated that the wound was “debris-filled,” so the surgeon’s report should document debridement of a complicated laceration.

Best: Ideally, surgeons would be familiar with the criteria that identify wound closures as simple, intermediate, and complex, and use that terminology themselves in the report to clarify coding.