Our surgeon removed a chest wall tumor and following the resection documented the following closure: “The wound was irrigated out with saline and closed the deep tissue with 3-0 Dexon, the skin with a mixture of 4-0 nylon, 3-0 silk, and skin staples.” My question is not related to the code for the resection, but is related to the documentation for the closure. Can you advise if the previous documentation supports an intermediate or complex closure? Is this an intermediate or complex closure?
Answer:
There is no documentation of tissue undermining or advancement of skin to achieve the closure, thus it appears based on this documentation alone, it is an intermediate repair. Intermediate repairs are included in the closure of the new soft tissue musculoskeletal codes, thus based on the documentation provided, the repair is inclusive and not separately reportable.
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