Procedure Notes for Laceration Repair

Definition of Simple, Intermediate, complex repairs.

Simple repair is used when the wound is superficial involving primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures, and requires simple one layer closer.

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. Single layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair. Also make note if you have to trim the wound margins to align for repair.

Complex repair includes the repair of wounds requiring more than layered closure, scar revision, repair of the muscle belly ect. This includes multiple layer closures of face, ears, eyelids, nose lips, and/or mucous membranes. Procedures notes should be clear so the coder can bill/code for the correct Length and depth.

1.    Procedure notes should be brief and concise

• Anesthesia used 
• Type of injury (curved angular or stellate)
• Length & depth (in centimeters)
• Describe layered closure (suture Material)
• Condition of injury (contaminated wound, if you used copious amount of irrigation) 
• Debridement

2.    Laceration & Wound Repair

• Number of layers closed  
• Location of injury
• Length of Wound
• Extra cleaning or debridement beyond normal

Repair lip, full thickness; vermilion only, identifies the repair of a laceration that involves the full thickness of the lip and the vermilion border." It is important to note these type of repair in detail.

***It is important to list each wound separate due to the different CPT codes for different anatomical locations.***