Layered Closure with Lesion Excision

Question:

Our practice performs many excisions of lesions with closures. My question is related to the closures. Is the provider documenting the closure in layers enough to report an intermediate repair if the tissue level is not?

Answer:

Great question!

We know that lesion excisions and closure with either intermediate and/or complex closure are appropriate to report together if the documentation supports it. In contrast, closure with simple repair is an included lesion excision and is not separately reportable.

The CPT guidelines are essential and should be reviewed carefully, as the definitions of each closure type can be found here. To report a closure accurately, it is best practice to include the type or level of tissue being repaired. KZA would encourage you to review the CPT guidelines for closures with your practice for documentation purposes. As you can see from the guidelines within CPT, the type and tissue level are factored into the definitions.

*This response is based on the best information available as of 3/13/25.