Wound repair types and measurement, excision, biopsy, burns, fracture care terminology, and arthroscopy coding rules.
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- What is a simple wound repair?
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Repair of a wound involving only epidermis, dermis, or subcutaneous tissue, closed in a single layer with no deeper structure involvement.- What is an intermediate wound repair?
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Repair requiring layered closure of one or more deeper layers of subcutaneous tissue and superficial fascia, in addition to the skin closure.- What is a complex wound repair?
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Repair requiring more than layered closure, such as scar revision, debridement, extensive undermining, stents, or retention sutures.- When can a single-layer wound still be classified as intermediate repair?
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When it requires extensive cleaning or removal of particulate matter before closure.- How should lengths of multiple wounds be combined for coding?
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Add together only wounds of the same repair classification and same anatomic grouping.- Can a simple wound and a complex wound in the same region be summed into one code?
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No, each classification is measured and coded separately.- In what unit is wound repair length reported for coding?
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Centimeters.- Which anatomic grouping in wound repair coding includes scalp, axillae, trunk, and extremities?
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One of CPT's two anatomic site groupings for repair codes, separate from face, ears, eyelids, nose, lips, and mucous membranes.- Is local anesthesia infiltration separately billable when performing a wound repair?
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No, it is included in the wound repair code.- What is adjacent tissue transfer?
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A reconstructive technique that moves nearby skin and tissue to cover a defect, coded by total square centimeters rather than the repair codes.- When may debridement be reported separately alongside a simple wound repair?
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When extensive removal of gross contamination or devitalized tissue is required before closure.- What does the margin in a lesion excision represent?
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The narrowest amount of normal tissue surrounding the lesion needed to completely excise it.- How is the size of an excised lesion calculated for code selection?
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The lesion's greatest diameter plus the margin required for complete excision.- Is a simple closure performed immediately after a lesion excision reported with a separate code?
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No, simple closure is included in the excision code.- When is a repair billed separately in addition to a lesion excision code?
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When the closure required is intermediate or complex rather than simple.
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