Coding Closure of Excision
I had someone recently ask me a question about closure. The question was is CPT code 11400 typically billed with a closure code. My response was that CPT code 11400 does include simple closure. Many want to code a closure code with the procedure in order to compensate for the closure. Simple closure is used when the wound is superficial (e.g. involving primarily the epidermis or dermis or subcutaneous tissues without significant involvement of deeper structures) and requires simple one layer closure. Intermediate closure 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 closure includes the repair of wounds that, in addition to the requirements for the intermediate repair, require at least one of the following: exposure of bone, cartilage, tendon , or named neurovascular structure; debridement of wound edges (e.g. 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, vermilion border , or nostril rim; placement of retention sutures. For simple closures you would use CPT codes 12001-12021. For intermediate closures you would use CPT codes 12031-12057. For complex closures you would use CPT codes 13100-13153. Each closure code is dependent on size of closure and location.
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