Complex Wound Closure / Local Flap

CPT 13100
Approach Open
Add-on / Variant CPTs
  • 13101 — Complex repair, each additional 5 cm
  • 14000 — Adjacent tissue transfer (Z-plasty, rotation flap), trunk
  • 14060 — Adjacent tissue transfer, eyelids, nose, ears, lips
  • 14040 — Adjacent tissue transfer, scalp, arms, legs
Preoperative Diagnosis:

Complex wound [location] requiring reconstruction

Postoperative Diagnosis:

Same

Procedure Performed:

Complex wound closure [with / without] local flap, [location]

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident/Fellow/PA name]

Anesthesia:

Local with sedation / general
Patient positioned for optimal access to wound.

Indications:

Patient presents with [traumatic wound / post-excision defect / dehisced wound] measuring [X x Y] cm on the [location]. Primary closure [not possible due to tension / skin deficiency / location]. [Reconstructive ladder assessed.] Local tissue rearrangement planned. Risks including wound dehiscence, infection, flap necrosis, and scarring discussed. Consent obtained.

Findings:

Wound [X x Y] cm. Wound bed [clean / granulating / with exposed [tendon / bone / hardware]]. Local tissue mobility adequate for [rotation / advancement / transposition] flap. [No signs of infection.]

Description of Procedure:

The patient was positioned and prepped in sterile fashion. Local anesthesia infiltrated [1% lidocaine with 1:100,000 epinephrine].
The wound was debrided of all non-viable tissue and margins freshened. The defect measured [X x Y] cm. [Reconstructive plan: rotation flap / advancement flap / Z-plasty / rhomboid flap / bilobed flap.]
[Rotation flap:] A rotation flap was designed with a radius [X] times the defect width. The flap was incised and elevated in the [subcutaneous / submuscular] plane. The flap was rotated to cover the defect without tension. Donor site [closed primarily / covered with STSG].
[Z-plasty:] The Z-plasty limbs were designed at [60-degree] angles to the central limb. Flaps elevated and transposed. This effectively lengthened the scar by [73%] and reoriented it along relaxed skin tension lines.
All layers closed in sequence: deep dermis with 3-0 Vicryl, skin with 4-0 Monocryl subcuticular [or nylon interrupted]. Wound approximation without tension confirmed. Dressing applied. Patient tolerated the procedure well.

Complications:

None

Specimens:

[Wound margin biopsy sent / None]

Estimated Blood Loss:

Minimal

Drains:

[Drain placed / None]

Disposition:

Patient discharged to home / PACU in stable condition.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Complex wound, [location], requiring reconstruction
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Complex wound closure [with local flap: rotation / advancement / Z-plasty], [location]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: [Local with sedation / general]

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with a [traumatic wound / post-excision defect / dehisced wound] measuring *** × *** cm on the [location]. Primary closure not possible due to [tension / skin deficiency]. Local tissue rearrangement planned. Risks including wound dehiscence, infection, flap necrosis, and scarring were discussed. Informed consent obtained.

FINDINGS: Wound *** × *** cm. Wound bed [clean / granulating / with exposed tendon/bone]. Local tissue mobility adequate for [rotation / advancement / transposition] flap. No signs of infection.

DESCRIPTION OF PROCEDURE:
Patient positioned and prepped in sterile fashion. 1% lidocaine with 1:100,000 epinephrine infiltrated. Wound debrided of non-viable tissue. Margins freshened. Defect measured *** × *** cm. [ROTATION FLAP: Flap designed with radius *** times the defect width; elevated in the [subcutaneous / submuscular] plane; rotated to cover defect without tension; donor site closed primarily.] [Z-PLASTY: Limbs designed at 60-degree angles to central limb; flaps elevated and transposed, lengthening scar and reorienting along relaxed skin tension lines.] [ADVANCEMENT FLAP: *** × *** cm flap raised; advanced to cover defect.] Deep dermis closed with 3-0 Vicryl, skin with 4-0 Monocryl subcuticular. Wound approximation without tension confirmed. Dressing applied. Patient tolerated the procedure well.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: [Wound margin biopsy / None]
COMPLICATIONS: None
DRAINS: [Drain placed / None]
DISPOSITION: Patient taken to PACU in stable condition. Discharged to home.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Rhomboid (Limberg) flap

For rhomboid-shaped defects. Document 60-120 degree design, flap elevation, and transposition.

Bilobed flap

For nasal tip and lateral nose defects. Two-lobe design, 45 degrees each. Document nasal anatomy preservation.

Keystone flap

For extremity and trunk defects. Island advancement flap. Document perforator preservation and fascial release for advancement.

Charting Tips
  • CPT selection depends on surface area (complex repair) vs. flap type (adjacent tissue transfer)
  • Document wound dimensions and location, as these drive CPT selection and support medical necessity
  • State flap design, pedicle, and degree of transposition/advancement
  • Document tension at closure and any retention sutures
  • For exposed hardware or bone: document coverage achieved and wound bed vascularity
Billing Tips
  • Code selection depends on anatomic region and total wound length: 13100–13102 (trunk, 2.93–3.41 wRVU primary + 1.21 add-on per 5 cm) vs 13120–13122 (scalp/arm/leg, 3.15–3.90 wRVU) vs 13131–13133 (face/neck/genitalia, 3.64–4.66 wRVU).
  • Measure and document the total wound length in cm. This drives code tier selection and is auditable.
  • Add-on codes (13102, 13122, 13133) are used for each additional 5 cm beyond the initial segment. Bill once per additional 5 cm or fraction thereof.
  • Complex repair requires at least one of: layered closure, scar revision, retention sutures, extensive undermining, or debridement. Document which applies.
  • If multiple wounds are closed, total wounds in the same anatomic region. Wounds in different regions are billed separately with the appropriate region code.
  • Global period is 10 days (minor). Post-op wound checks within 10 days are bundled. Unexpected complications requiring return to OR can be unbundled with modifier -78.
  • Do not downcode to intermediate repair (12xxx). If the closure qualifies as complex, document and bill correctly.