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A complex repair of a wound of the trunk involves a detailed and meticulous approach to wound management. This procedure is necessary when a wound requires more than a simple layered closure, indicating that the injury is more extensive or complicated. Initially, the wound is thoroughly cleansed to remove any debris or contaminants, and a local anesthetic is administered to ensure patient comfort during the procedure. The surgeon inspects the wound to assess its complexity, which may involve excising a scar if the repair is for scar revision. In cases of traumatic lacerations or avulsions, the wound is not only cleansed but also debrided, which may involve the removal of dead or damaged tissue using sharp dissection techniques. To minimize tension on the wound during closure, tissues may be extensively undermined, allowing for better alignment of the wound edges. Control of bleeding is crucial and can be achieved through chemical means or electrocautery. The closure technique varies based on the wound's location and nature; deeper layers may be closed with absorbable sutures, while non-absorbable sutures are used for the superficial layers. In some cases, retention sutures are employed to hold the wound edges together without exerting tension, utilizing a method where a short length of plastic or rubber tubing is threaded over each suture before tying. Additionally, stents may be utilized to maintain tissue position or keep an orifice open. Throughout the procedure, careful attention is given to align the wound edges properly to prevent complications such as scar depression. For coding purposes, the add-on code CPT® 13102 is used for each additional 5 cm or less of wound length when the primary procedure codes 13100 or 13101 have been applied for wounds measuring 1.1 to 2.5 cm and 2.6 to 7.5 cm, respectively.
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The complex repair of a wound of the trunk is indicated for various conditions that necessitate a more intricate approach to wound closure. These include:
The procedure for a complex repair of a wound of the trunk involves several critical steps to ensure effective healing and minimize complications. The first step is to thoroughly cleanse the wound to remove any foreign materials and contaminants. Following this, a local anesthetic is administered to ensure the patient remains comfortable throughout the procedure. The surgeon then inspects the wound to determine its complexity, which may involve excising a scar if the repair is for scar revision. In cases of traumatic lacerations or avulsions, the wound is carefully debrided to remove any dead or damaged tissue, which may be accomplished through sharp dissection techniques. To facilitate proper closure, the surgeon may undermine the surrounding tissues extensively, which helps to reduce tension on the wound edges. This is a crucial step as it allows for better alignment and closure of the wound. Once the wound is prepared, bleeding control is achieved through chemical means or electrocautery, ensuring a clean field for closure. The closure technique varies based on the wound's characteristics; deeper layers may be closed using absorbable sutures, with the knots buried to prevent irritation. The superficial layers are typically closed with non-absorbable sutures. In some instances, retention sutures are utilized to hold the edges of the wound together without tension. This involves placing sutures through the entire thickness of the wound, threading a short length of plastic or rubber tubing over each suture, and then tying them securely. Additionally, stents may be employed to maintain tissue position or keep an orifice open. Throughout the procedure, careful attention is given to align the wound edges properly 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 wound. Follow-up appointments are often scheduled to assess healing and remove sutures if necessary. Patients may also be advised on signs of complications to watch for, ensuring prompt medical attention if issues arise. Overall, proper post-procedure care is crucial to achieving the best possible outcomes following a complex repair of a wound of the trunk.
| Short Descr | CMPLX RPR TRUNK ADDL 5CM/< | Medium Descr | REPAIR COMPLEX TRUNK EACH ADDITIONAL 5 CM/< | Long Descr | Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure) | Status Code | Active Code | Global Days | ZZZ - Code Related to Another Service | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 0 - No 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 | Items and Services Packaged into APC Rates | ASC Payment Indicator | Packaged service/item; no separate payment made. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6B - Minor procedures - musculoskeletal | MUE | 9 | CCS Clinical Classification | 171 - Suture of skin and subcutaneous tissue |
This is an add-on code that must be used in conjunction with one of these primary codes.
| 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. | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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.) | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | 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. | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 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.) | 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. | CR | Catastrophe/disaster related | RT | Right side (used to identify procedures performed on the right side of the body) | LT | Left side (used to identify procedures performed on the left side of the body) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | 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. | 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). | 77 | Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | FT | Unrelated evaluation and management (e/m) visit on the same day as another e/m visit or during a global procedure (preoperative, postoperative period, or on the same day as the procedure, as applicable). (report when an e/m visit is furnished within the global period but is unrelated, or when one or more additional e/m visits furnished on the same day are unrelated) | GA | Waiver of liability statement issued as required by payer policy, individual case | 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 | GZ | Item or service expected to be denied as not reasonable and necessary | KX | Requirements specified in the medical policy have been met | PO | Excepted service provided at an off-campus, outpatient, provider-based department of a hospital | 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 | SA | Nurse practitioner rendering service in collaboration with a physician | 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. |
| 2000-01-01 | Added | First appearance in code book in 2000. |
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