What is the Difference Between a Simple Repair of a Wound, an Intermediate Repair of a Wound and a Complex Repair of a Wound?
Simple repair is used when the wound is superficial (eg. involving primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures) and requires simple one-layer closure. Hemostasis and local or topical anesthesia, when performed, are not reported separately.
Intermediate repair includes the repair of wounds that, in addition to the above, require layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure. It includes limited undermining (defined as a distance less than the maximum width of the defect, measured perpendicular to the closure line, along at least one entire edge of the defect). Single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair.
Complex repair includes the repair of wounds requiring more than layered closure that, in addition to the requirements for intermediate repair, require at least one of the following: exposure of bone, scar revision cartilage, tendon, or named neurovascular structure; debridement of wound edges (eg, traumatic lacerations or avulsions); extensive undermining (defined as a distance greater than or equal to the maximum width of the defect, measured perpendicular to the closure line along at least one entire edge of the defect); involvement of free margins of helical rim, stents vermilion border, or nostril rim; placement of retention sutures. Necessary preparation includes creation of a limited defect for repairs or the debridement of complicated lacerations or avulsions. Complex repair does not include excision of benign (11400-11446) or malignant (11600- 11646) lesions, excisional preparation of a wound bed (15002-15005) or debridement of an open fracture or open dislocation.
Addendum: The reference in the article to the OIG is not a new OIG initiative. This has simply been ongoing.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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