Cracking the Code
Coding repairs can seem daunting to some; however, the process is laid out nicely in our CPT code books. Our CPT code books have guidelines specifically for repairs. First, we want to understand the difference behind a simple, intermediate and complex repair. A simple repair is a one-layer closure, which can be superficial, epidermis, dermis, or subcutaneous tissue. Simple repairs are primarily used when the wound is superficial. Next is intermediate repair. This is a layered closure including deeper layers of subcutaneous tissue and non-muscle fascia, or a single layered closure of heavily contaminated wounds requiring extensive cleansing or removal of specific matter. Finally, we have a complex repair. Complex repairs require more than a layered closure such as debridement, extensive undermining stents or retention sutures to name a few examples.
When we are coding repairs, we always want to begin with the highest level of repair first. Documentation should include location of the repair, length of the repair, depth in terms of centimeters, description of the appearance, and the type of repair such as simple, intermediate, or complex.