When it comes to CPT® coding, wound repair is typically classified as simple, intermediate, or complex. Full guidelines regarding use of these codes can be found in the CPT Professional book. There are precise guidelines that help providers determine whether a wound closure was simple, intermediate or complex and there is no subjectivity involved in this selection process.
Simple repair occurs when the wound is superficial (eg, involving primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures) and requires simple one-layer closure.
Intermediate repair requires simple repair and either:
- Limited undermining and layered closure of subcutaneous tissue and / or superficial fascia, and skin closureOR
- Single-layer closure of a heavily contaminated wound that required extensive cleaning or removal of particulate matter
Complex repair requires meeting the requirements of intermediate repair and all three of the following:
- One of the two criteria of Intermediate Repair be met
- Preparation have been performed by either creation of a limited defect for repairs OR the debridement of complicated lacerations or avulsions.
- One of the following:• exposure of bone, cartilage, tendon, or named neurovascular structure
• debridement of wound edges
• extensive undermining
• involvement of free margins of the helical rim, vermilion border, or nostril rim
• placement of retention sutures
The selection of simple versus intermediate versus complex repair must be based on only the criteria listed above. In addition, it is important that the documentation support the code selection. When using one of these repair CPT codes, be sure the associated documentation includes the criteria listed above that is necessary to support the selection of that code.
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