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A complex repair of a wound of the trunk involves a detailed and meticulous surgical procedure aimed at addressing wounds that are larger and more complicated than simple lacerations. This type of repair is necessary when the wound requires more than just a straightforward layered closure, indicating that the injury may involve deeper tissues or significant trauma. 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. Upon inspection, if the wound is determined to necessitate a complex approach, the surgeon may excise any existing scar tissue if the repair is for scar revision. In cases of traumatic lacerations or avulsions, the wound is thoroughly cleansed, and any foreign materials are removed. Debridement may be performed using sharp dissection techniques to remove devitalized tissue, which is crucial for promoting healing. The surgeon may also undermine the surrounding tissues to reduce tension on the wound edges, which is essential for optimal healing and minimizing scarring. Control of bleeding is achieved through chemical means or electrocautery, ensuring a clean surgical field. The closure technique varies based on the wound's location and nature; deeper layers may be closed with absorbable sutures, while superficial layers are typically closed with non-absorbable sutures. In some cases, retention sutures may be employed to hold the wound edges together without exerting tension, utilizing plastic or rubber tubing to facilitate this process. Additionally, stents may be used to maintain tissue alignment or keep an orifice open. Throughout the procedure, careful attention is paid to align the wound edges properly to prevent complications such as scar depression. This code, 13100, specifically applies to complex repairs of trunk wounds measuring between 1.1 cm and 2.5 cm in length, while additional codes are available for longer wounds.
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The complex repair of a wound of the trunk is indicated for specific conditions that necessitate a more intricate surgical approach. These indications include:
The procedure for a complex repair of a wound of the trunk involves several critical steps, each designed to ensure optimal healing and aesthetic outcomes. The first step is the thorough cleansing of the wound to eliminate any contaminants and reduce the risk of infection. Following this, a local anesthetic is administered to ensure the patient remains comfortable throughout the procedure. Once the area is adequately anesthetized, the surgeon inspects the wound to determine the extent of the damage and whether a complex repair is warranted. If the procedure is for scar revision, the surgeon will excise the scar tissue to facilitate a fresh repair. In cases of traumatic lacerations or avulsions, the wound is meticulously cleaned, and any particulate matter is removed. Debridement may be performed using sharp dissection techniques to remove any non-viable tissue, which is essential for promoting healing. The surgeon may then undermine the surrounding tissues using scissors or a scalpel, which helps to minimize tension on the wound edges during closure. Bleeding control is a crucial aspect of the procedure, achieved through chemical agents or electrocautery to maintain a clear surgical field. The closure of the wound is tailored to its specific characteristics; the deepest layers may be closed with absorbable sutures, ensuring that the knots are buried to prevent irritation. The superficial layers are typically closed with non-absorbable sutures. In some instances, retention sutures may be utilized to hold the edges of the wound together without tension, which involves threading a short length of plastic or rubber tubing over each suture before tying them. Additionally, stents may be employed to maintain tissue alignment or keep an orifice open. Throughout the procedure, careful alignment of the wound edges is emphasized to prevent complications such as scar depression.
After the complex repair procedure is completed, post-procedure care is essential for optimal recovery. Patients are typically monitored for any signs of complications, such as infection or excessive bleeding. Instructions regarding wound care are provided, which may include keeping the area clean and dry, changing dressings as directed, and avoiding activities that could stress the repair site. Follow-up appointments are often scheduled to assess healing and remove any non-absorbable sutures if used. Patients may also receive guidance on managing pain and discomfort during the recovery period. It is crucial to adhere to all post-operative instructions to ensure proper healing and minimize the risk of complications.
| Short Descr | CMPLX RPR TRUNK 1.1-2.5 CM | Medium Descr | REPAIR COMPLEX TRUNK 1.1-2.5 CM | Long Descr | Repair, complex, trunk; 1.1 cm to 2.5 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 | Surgical procedure on ASC list in CY 2007; 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 |
This is a primary code that can be used with these additional add-on codes.
| 20701 | Add-on Code MPFS Status: Active Code APC N Removal of drug-delivery device(s), deep (eg, subfascial) (List separately in addition to code for primary procedure) |
| 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. | 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). | 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.) | 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 | QK | Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 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. | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 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 | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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) | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days | 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 | T6 | Right foot, second digit | 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 | Description Changed |
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