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Simple repair or intermediate repair

Hi,

Physician is making an incision and goes deeper layer of skin and after excising the scapular cyst he just closed the subcutaneous tissue with sutures and then skin with vicryl sutures.

In this physician is only doing incision to the deeper layer but the closure documentation states only closure of subcutaneous tissue and skin, not a layered closure I believe.

Please suggest that if it is simple closure or intermediate closure.

As per CPT definition: For Intermediate closure there should be documentation of deeper layer of subcutaneous tissue closure and then skin closure. But in the above documentation only incision is deeper but suggest if we can assume that physician is closing the wound with layers or we need to code it as simple repair.

I just want to know whether we need to see the incision documentation or closure documentation to code the multi layer closure or intermediate closure.

Medical Billing and Coding Forum – Dermatology