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Intermediate repair of wounds located on the face, ears, eyelids, nose, lips, and/or mucous membranes involves a surgical procedure designed to address injuries that penetrate deeper layers of tissue. This type of repair is necessary when the wound is not only superficial but also affects the subcutaneous tissue and superficial fascia, which are critical for the structural integrity and function of these sensitive areas. The procedure begins with the cleansing of the wound to prevent infection, followed by the administration of a local anesthetic to ensure patient comfort during the repair process. The surgeon inspects the wound to assess the extent of the damage, which may include the need for extensive cleaning or removal of debris in cases of contamination. During the repair, a layered closure technique is employed, utilizing sutures, staples, or tissue adhesive to bring the wound edges together securely. To minimize tension on the wound, the tissues may be undermined using surgical instruments such as scissors or a scalpel. Controlling bleeding is a critical aspect of the procedure, which can be achieved through chemical means or electrocautery. The closure process involves carefully stitching the deepest layers with absorbable sutures, ensuring that the knots are buried to reduce irritation and promote healing. The superficial layer is then closed with attention to aligning and everting the wound edges, which is essential to prevent the formation of a depressed scar. This procedure is specifically indicated for wounds measuring between 5.1 cm and 7.5 cm, and it is important to select the appropriate CPT® code based on the size of the wound, with specific codes designated for varying lengths of wounds.
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The intermediate repair of wounds of the face, ears, eyelids, nose, lips, and/or mucous membranes is indicated for the following conditions:
The procedure for intermediate repair of wounds involves several critical steps to ensure effective closure and optimal healing. First, the wound is thoroughly cleansed to eliminate any debris and reduce the risk of infection. Following this, a local anesthetic is administered to numb the area, allowing the patient to remain comfortable throughout the procedure. The surgeon then inspects the wound to determine its depth and complexity, confirming that it involves deeper layers of tissue, such as the subcutaneous tissue and superficial fascia. If the wound is found to be heavily contaminated, the surgeon may need to perform extensive cleaning to remove any particulate matter. Once the wound is prepared, the closure process begins. A layered closure technique is employed, which may involve the use of sutures, staples, or tissue adhesive. To minimize tension on the wound during closure, the surgeon may undermine the surrounding tissues using scissors or a scalpel. Bleeding control is an essential part of the procedure, which can be achieved through chemical methods or electrocautery. The deepest layers of the wound are then closed with absorbable sutures, ensuring that the knots are buried to prevent irritation. Finally, the superficial layer is closed with careful attention to the alignment and eversion of the wound edges, which is crucial for preventing a depressed scar. This meticulous approach is particularly important for wounds located on the face and other visible areas.
After the intermediate repair procedure, patients can expect specific post-procedure care to promote healing and minimize complications. The area should be kept clean and dry, and patients are typically advised to avoid strenuous activities that may stress the wound. Follow-up appointments may be necessary to monitor the healing process and to remove any non-absorbable sutures if used. Patients should be informed about signs of infection, such as increased redness, swelling, or discharge, and instructed to contact their healthcare provider if these symptoms occur. Additionally, proper wound care instructions should be provided to ensure optimal recovery and cosmetic outcomes.
| Short Descr | INTMD RPR FACE/MM 5.1-7.5 CM | Medium Descr | REPAIR INTERMEDIATE F/E/E/N/L&/MUC 5.1-7.5 CM | Long Descr | Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm | Status Code | Active Code | Global Days | 010 - Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6A - Minor procedures - skin | MUE | 1 | CCS Clinical Classification | 171 - Suture of skin and subcutaneous tissue |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 54 | Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | AG | Primary physician | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | E1 | Upper left, eyelid | E4 | Lower right, eyelid | GA | Waiver of liability statement issued as required by payer policy, individual case | GJ | "opt out" physician or practitioner emergency or urgent service | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GW | Service not related to the hospice patient's terminal condition | LT | Left side (used to identify procedures performed on the left side of the body) | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner |
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| 2013-01-01 | Changed | Short Descriptor changed. |
| 2009-01-01 | Changed | Code description changed |
| Pre-1990 | Added | Code added. |
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