Wiki Complex repair or intermediate

[JesseL]

Should the operative note be coded under intermediate repair or complex repair. I thought of coding 12020 but that's only for single layer not two layers. Help appreciated.

Disruption of external operation (surgical) wound, NEC, init
Open wound and dehiscience of surgical wound located on right cheek
Medical Decision Making: Disruption of external operation (surgical) wound, NEC, init , observe

Injected Lidocaine 2% over open wound. Used scalpel to run through wound.repair of dehisced wound performed in office today. 4-0 polysorb x 2 buried sutures were put into the subcutaneous layer. 4-0 monosof x 3 interrupted sutures were put into top layer. Steristrips applied. bacitracin applied. pressure dressing applied. Advised pt to apply bacitracin or mupirocin ointment once daily with a q-tip. Suture length 2.0cm. Gave solodyn 115 mg to take po once daily after a meal. f/u forsuture removal in 2 weeks. Avoid excessive strenuous exercises.

 

[thomas7331]

I would code this as intermediate. CPT defines complex as 'the repair of wounds requiring more than layered closure, viz., scar revision, debridement...extensive undermining, stents or retention sutures. Necessary preparation includes creation of a limited defect for repairs or the debridement of complicated lacerations or avulsions.' This example qualifies as intermediate because the provider has documented the closure of two layers.