Surefire Tips to Identify Wound Repair Level

Wound repair causes a lot of confusion among medical billers and medical coders. It’s not always easy to identify the level of wound repair involved when reading an operative report. If you cannot quickly ascertain the level of wound repair, then you need to check for a few things. In order to identify wound repair level, you should look to the operative report for these key words and clues:

-If a surgeon mentions single layer closure in his or her operative report, it is a simple repair. Simple repairs involve superficial wounds that involve “primarily epidermis, or dermis or subcutaneous tissues without significant involvement of deeper structures” according to the CPT. Surgeons will refer to these types of repairs as single layer closures.

– If a surgeon mentions “layered closure” in his or her operative report, then you probably have an intermediate repair. Intermediate repairs are more extensive, involving “one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin closure” according to the CPT.

-If a surgeon mentions a repair to the depth of muscle, or deeper, then it is complex. Complex repairs will involve more than just a layered closure, and may include extensive undermining, stents, or retention sutures.

Remember that it is not a good idea to guess. If the operative report does not provide you with enough sufficient detail to determine, beyond a doubt, the level of wound repair, then check with the operating surgeon to see what level of wound repair was involved in the procedure in question.

View all Articles by: Kathryn E, CCS-P - Retired