General Surgery Coding Alert

To identify the level of wound repair, look to the operative report for these key words and clues:

- Simple repairs involve superficial wounds that involve -primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures,- according to CPT. Surgeons will refer to these as single-layer closures.

- Intermediate repairs are more extensive and involve -one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure,- according to CPT. If the surgeon mentions -layered closure,- you probably have an intermediate repair.

- Complex repairs involve more than layered closure, such as extensive undermining, stents or retention sutures. If the surgeon mentions repair to the depth of muscle or deeper, it's complex.

Don't take a guess: If the operative report does not provide sufficient detail to determine beyond doubt the repair level, check with the operating surgeon.