Chapter 6: CPT Coding System—
General Procedure and Integumentary
INTRODUCTION
Codes in this section are used to describe general procedures and those performed on
the integumentary system. The integumentary section includes codes for procedures
performed on the skin, nails, and breasts; including repair of lacerations, removal of
lesions, insertion, and removal of subcutaneous contraceptive devices, treatment of
decubitus ulcers, breast surgeries, and reconstruction.
Determine the type of treatment rendered (e.g., destruction, excision, incision),
anatomical location and when appropriate, size of the lesion or repair. The
integumentary system section of the CPT book includes the following eight
subsections:
•
•
•
•
•
•
•
•
General
Skin, Subcutaneous and Accessory Structures
Nails
Pilonidal Cyst
Introduction
Repair (closure)
Destruction
Breast

OBJECTIVES
• Identify the integumentary system
structures
• Explain incision, drainage,
debridement procedures
• Review procedures on the nails
• Define biopsies and excisions
• Explain the types of skin and tissue
repairs
• Describe Mohs surgical procedures
• Review breast procedures
GUIDELINES AND EXPLANATIONS
Repair or Closure
The codes in this section are used to report the repair or closure of skin and soft
tissue. The procedure report may indicate that sutures, staples, or tissue adhesive
(glue) was used for the repair.
Coding Guidelines
CPT guidelines indicate that repair using tape, steri strips, or other adhesive material
only is included in evaluation and management services
.
There are three classifications of repairs, simple, intermediate and complex. They are
defined as:
© 2014 OptumInsight, Inc.
CPT © 2013 American Medical Association. All Rights Reserved.
1
Optum Learning: Comprehensive Coding Guide
For layered closue of wounds of the neck
Example of complex layered
suturing involving deeper tissues
Simple: Surgical closure of a superficial wound, requiring single layer suturing of the
skin (epidermis, dermis, or subcutaneous tissue).
Intermediate: 1) Surgical closure of a wound requiring closure of one or more of the
deeper subcutaneous tissue and non-muscle fascia layers in addition to the skin. 2)
Contaminated wounds with single layer closure that need extensive cleaning or
foreign body removal.
Complex: Surgical closure of a wound requiring more than layered closure of the
deeper subcutaneous tissue and fascia (i.e., debridement, scar excision, placement of
stents or retention sutures, and sometimes site preparation or undermining that
creates the defect requiring complex closure).
Additional instructions state:
• The length of the wound repairs is reported in centimeters
• Multiple wounds from the same body site that were repaired using the same type
of closure technique (simple, intermediate or complex) should be coded as one
wound
• Add the measurements of each wound for each group of anatomic sites and
assign a single code for the repair
• When multiple repair classifications are documented, report the most complex
first (e.g., complex, then intermediate, followed by simple)
Case Example
One: A five year old fell from a swing at the park. The provider documents a single layer
closure of a 2.5 cm wound of the scalp and a single layer closure of a 3.0 cm wound of the
right elbow.
These are both single layer closures. They are both in the grouping of simple repair of the
“scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet)” in
codes 12001-12007. The coder will combine the 2.5 cm and the 3.0 cm repairs for a total of 5.5
cm. The correct code is 12002 for a repair that is 2.6 cm or greater but less than 7.5 cm.
Two: The server dropped a tray of glasses at the restaurant with multiple wounds to the left
lower leg. The provider documents a two layer closure of a 4.3 cm laceration of the left lower
leg and a single layer closure of a 3.0 cm laceration of the left lower leg.
The two lacerations are of different classifications. The two layer closure is an intermediate
repair of the extremity and reported with code 12032 s it is 4.3 cm. The single layer closure is a
simple repair of the extremity and reported with code 12002 as it is 3.0 cm. The intermediate
repair is more complex and reported before the simple repair.
• A single layer repair that requires extensive debridement is reported as an
intermediate repair
2
© 2014 OptumInsight, Inc.
CPT © 2013 American Medical Association. All Rights Reserved.
Chapter 6: CPT Coding System— General Procedure and Integumentary
• An intermediate (layered) repair that requires extensive debridement is reported
as a complex repair
• Debridement without repair is reported separately (see 11000-11047)
• Exploration of an open wound with inspection of other structures (nerves, blood
vessels, tendons) is considered inherent in the procedure
• Ligation of vessels without repair are not separately reported
• When other structures are repaired the closure of the skin is included in the
repair of the nerve, blood vessel, tendon or other structures
Case Example
Three: The 17 year old boy was “planking” with friends and fell six feet onto a fence post with
a deep wound of his upper arm. The provider documented that the nerves and vessels were
intact. The wound was thoroughly irrigated and the wound margins were debrided and
trimmed. A 7.0 cm repair of the muscle, fascia, and skin was performed.
Only the complex repair of the multiple layers of the arm is reported. The debridement is not
extensive or of another area and does not require an additional code. The inspection of
nerves and blood vessels is included in the repair. This services is reported with code 13121,
Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm. Note that if this wound had been
more than 7.5 cm code 13122 would have been reported for each additional 5.0 cm that was
repaired.
Answer the following questions about wound repairs to help code accurately:
•
•
•
•
•
•
•
•
•
•
•
•
How many wounds were repaired?
What is the anatomic site of the wound?
What is the length of the wound?
What type of repair was performed?
Is an adhesive strip applied?
Is chemical or electrocauterization employed?
Does the documentation state simple? Intermediate? Complex?
Is debridement performed?
Are blood vessels, tendons, or nerves repaired?
Is the wound explored and are the vessels ligated?
Is secondary wound repair performed?
If multiple wounds were repaired with the same type of closure technique, are
any of the wounds in the same anatomical grouping?
Guideline Assessment 6-x
Select the correct codes for each of the following scenarios:
1. The provider documented a single layer repair using tissue adhesive of a 2.0
cm laceration of the scalp. ____________________
2. An intermediate or complex repair involves the deeper _______________
________________ and ________________ structures.
3. Wound contamination or extensive cleaning and debridement does not
affect the type of repair.
a. True
b. False
4. Wounds of the same ____________________ and __________________
site groupings are combined to a single code.
© 2014 OptumInsight, Inc.
CPT © 2013 American Medical Association. All Rights Reserved.
3
Optum Learning: Comprehensive Coding Guide
ANSWERS TO GUIDELINE ASSESSMENTS
Assessment 6-x
1. 12001
The guideline under the header “Repair (Closure” in CPT states that wound
closure may utilize “sutures, staples, or tissue adhesives.” If the only closure is
with tissue adhesive then the repair is considered to be simple or a single layer
closure.
2. An intermediate or complex repair involves the deeper subcutaneous tissue
and fascia structures.
The definition of an intermediate repair in CPT indicates that subcutaneous
tissue and fascia are included. A complex repair usually involves deeper repair
than intermediate and would also include the subcutaneous tissue and fascia.
3. False
The guidelines for intermediate and complex repair indicate that a simple repair
with extensive cleaning or debridement is reported using the intermediate repair
codes. The guidelines also indicate that an intermediate repair involving
extensive cleaning or debridement is reported with the complex repair codes.
4. Wounds of the depth (or type) and anatomical site groupings are combined
to a single code.
Instruction 2 of this section indicates that the lengths of multiple wounds of the
same depth or type and anatomical grouping are added together and reported
with a single code.
4
© 2014 OptumInsight, Inc.
CPT © 2013 American Medical Association. All Rights Reserved.