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2012 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 8. Physician : 8.2 Services, Benefits, Limitations, and Prior Authorization : 8.2.23 Closure of Wounds

The repair of wounds is defined as simple, intermediate, or complex. Simple repair involves the dermis and subcutaneous tissue and requires a one‑layer closure. Intermediate repair requires some layered closure of deeper layers of subcutaneous tissue and superficial fascia. Complex repair involves more layered closure, debridement, extensive undermining, stints, or retention sutures.
Wound closures may use sutures, staples, or tissue adhesives. Wounds closed with adhesive strips must not be reported using wound closure procedure codes. When adhesive strips are the only wound closure material used, providers must report the most appropriate E/M visit procedure code on their claim.
Simple exploration of nerves, blood vessels, or tendons exposed in an open wound is considered inclusive to the wound closure and will not be reimbursed separately.
The lengths of multiple closures of wounds must be added together and billed as one procedure code if they meet at least one of the following criteria:
Providers must submit the procedure code that represents the total length of the repairs. Lengths of repairs from different CPT classifications or groupings of anatomic sites must be billed as separate procedure codes.
Wound closures must be billed using the following procedure codes:
Multiple wounds on the same day will be paid the full‑allowed amount for the major (largest total length of the repair at the same anatomic site) wound and one‑half the allowed amount for each additional laceration (total length of the repair at the same anatomic site).
No separate payment will be made for incision closures billed in addition to a surgical procedure when the closure is part of that surgical procedure.
No separate payment will be made for supplies in the office.
When the debridement is carried out separately without immediate primary closure, when gross contamination requires prolonged cleansing, or when large amounts of devitalized or contaminated tissue are removed, debridement may be reimbursed separately. Debridement rendered during the same surgical session as wound closure is considered inclusive to the closure and is not reimbursed separately.
Refer to:
Subsection, “Supplies, Trays, and Drugs,” in this handbook for the hospital‑based emergency department.
Wound suture and wound closure are considered part of any surgical procedure performed on the same area, with the following exceptions:
For excision of benign malignant lesion procedure codes requiring more than simple closure, providers may be reimbursed for the appropriate intermediate or complex closure procedure code. Multiple surgery guidelines apply.
The exceptions listed above apply to the following excision and closure procedure codes:s

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