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Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure)

CPT4 code

Name of the Procedure:

Repair, complex, trunk; each additional 5 cm or less

Summary

In layman's terms, this procedure involves surgically repairing a complex wound or defect on the trunk of the body. The area covered is typically five centimeters or less and is an additional repair performed on top of a primary procedure.

Purpose

This procedure addresses complicated wounds on the trunk which may be due to trauma, surgery, or chronic conditions. The goal is to restore the skin and underlying tissues to their normal structure and function, promoting healing and reducing the risk of infection or other complications.

Indications

  • Large or deep wounds on the trunk
  • Complex lacerations or tears that cannot heal properly on their own
  • Surgical closures following the removal of significant tissue (e.g., tumors)
  • Chronic ulcers or non-healing wounds

Preparation

  • Follow pre-procedure instructions, like fasting for a specific period.
  • Adjust medications as advised by your healthcare provider.
  • Undergo necessary diagnostic tests (e.g., blood tests, imaging).

Procedure Description

  1. The patient is administered local, regional, or general anesthesia.
  2. The surgeon cleans the wound and surrounding area.
  3. The wound edges are meticulously approximated using sutures, sometimes complemented by tissue grafts or flaps if necessary.
  4. Step-by-step suturing or application of other medical adhesives to secure and close the wound.
  5. The area is bandaged to protect the wound and promote healing. Tools include sterile surgical instruments, sutures, medical adhesives, and possibly grafting materials.

Duration

30 minutes to 2 hours, depending on the wound's complexity and size.

Setting

This procedure is typically performed in a hospital or an outpatient surgical center.

Personnel

  • Surgeon
  • Surgical nurse
  • Anesthesiologist (if general anesthesia is used)
  • Operating room technician

Risks and Complications

  • Infection at the wound site
  • Poor wound healing or scarring
  • Bleeding or hematoma formation
  • Allergic reactions to anesthesia or sutures
  • Rarely, need for additional surgeries

Benefits

  • Enhanced healing of complex wounds
  • Reduced risk of infection and other complications
  • Improved cosmetic and functional outcome Benefits may be realized within weeks as the wound heals and tissue integrity is restored.

Recovery

  • Follow post-operative care instructions, including keeping the wound clean and dry.
  • Take prescribed medications, such as antibiotics or pain relievers.
  • Attend follow-up appointments for wound evaluation and suture removal.
  • Avoid strenuous activities until cleared by your doctor.
  • Full recovery may take several weeks.

Alternatives

  • Conservative wound care with dressings and topical treatments
  • Negative pressure wound therapy (wound VAC)
  • Secondary intention healing (allowing the wound to heal from the inside out) Each alternative varies in effectiveness and suitability depending on wound size, depth, and patient health status.

Patient Experience

During the procedure, if local anesthesia is used, the patient may feel pressure but should not experience pain. With general anesthesia, the patient will be asleep. Post-procedure, there may be discomfort, which is manageable with medications. Instructions on pain management, wound care, and activity restrictions will be provided to ensure a smooth recovery.

Medical Policies and Guidelines for Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure)

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