Summary & Overview
CPT 1461F: Specific Clinical Documentation Measure
CPT code 1461F is a CPT-designated code with no summary provided in the source input. Nationally, properly labeled CPT codes are essential for clinical documentation, quality measurement, and claims processing across public and private payers. This code’s absence of a descriptive summary highlights potential gaps in documentation that can affect coding consistency, claims adjudication, and performance reporting. Key payers covered in this overview include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will gain: an understanding of what the code represents where available, the implications of missing descriptive information for billing and reporting, and what types of benchmarks and policy implications are typically reviewed when evaluating CPT codes. The content outlines available clinical context, notes where source data is missing, and identifies areas that organizations commonly address when a CPT code lacks an explicit summary — such as updating coding references, aligning clinical documentation, and coordinating with payers for claims clarity. This material is written for a national audience and focuses on documentation and coding implications rather than payer-specific claim strategies.
Billing Code Overview
CPT code 1461F has no summary available in the source description. Based on the code label, this entry represents a specific clinical documentation or performance measure identified by the CPT coding system. Service type: Data not available in the input. Typical site of service: Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A typical patient is an adult presenting to an outpatient surgical clinic for evaluation of a chronic or recurrent non-healing wound or traumatic soft-tissue defect requiring local tissue rearrangement or skin grafting. The clinic visit includes informed consent, preoperative assessment, and scheduling of a minor operative procedure performed under local anesthesia with or without conscious sedation in an ambulatory surgery center or hospital outpatient department. The procedure involves closure or reconstruction of a cutaneous defect after excision, debridement, or biopsy, and includes intraoperative assessment of tissue viability, hemostasis, and application of dressings. Postoperative care includes routine wound checks, dressing changes, and instruction on activity restrictions and wound care. Typical workflow: preoperative evaluation by the surgeon and nursing staff → procedure room preparation and time-out → administration of local anesthetic or sedation → lesion excision or debridement → local tissue rearrangement, primary closure, or skin grafting as indicated → hemostasis and dressing application → discharge with follow-up visit scheduled.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the day of a procedure | Use when a distinct E/M visit is provided on the same day as the procedure and is documented as separate from the surgical service |
59 | Distinct procedural service | Use to indicate a procedure or service was distinct or independent from other services performed on the same day |
24 | Unrelated E/M service by the same physician during a postoperative period | Use when an unrelated E/M is provided during the global postoperative period |
57 | Decision for surgery | Use when the E/M service resulted in the initial decision to perform surgery |
78 | Return to the operating room for a related procedure during the postoperative period | Use when a related procedure during the global period requires return to the operating room |
79 | Unrelated procedure or service by the same physician during the postoperative period | Use when an unrelated procedure is performed during the global period |
22 | Increased procedural services | Use when work required to perform the procedure is substantially greater than typically required |
52 | Reduced services | Use when the service provided was partially reduced or eliminated at the physician's discretion |
76 | Repeat procedure or service by same physician | Use when the same procedure is repeated later the same day |
77 | Repeat procedure by another physician | Use when a different physician repeats the procedure on the same day |
50 | Bilateral procedure | Use to identify bilateral procedures when applicable and when distinct codes do not exist |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
| 207P00000X | General Surgery | Surgeons who perform outpatient excisions, closures, and basic reconstructive procedures |
| 207L00000X | Plastic Surgery | Specialists in soft-tissue reconstruction, grafting, and complex closures |
| 208000000X | Dermatology | Dermatologists performing excisions, biopsies, and skin closures |
| 363A00000X | Podiatric Medicine & Surgery | Podiatrists performing soft tissue procedures on the foot and ankle |
| 207V00000X | Otolaryngology | ENT surgeons performing cutaneous and mucosal reconstructions in head and neck area |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
L98.4 | Non-healing surgical wound | Indicates wounds that fail to progress toward healing and may require surgical revision or reconstruction |
S81.809A | Open wound of unspecified lower leg, initial encounter | Represents traumatic open wounds requiring debridement and closure or grafting |
S01.81XA | Laceration without foreign body of head, initial encounter | Common traumatic mechanism leading to defect requiring repair or reconstruction |
L89.309 | Pressure ulcer of sacral region, unstageable | Chronic tissue loss that may necessitate surgical debridement and reconstruction |
C44.91 | Basal cell carcinoma of skin of unspecified site of face | After excision of skin cancer, defect closure or reconstructive procedure may be necessary |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
11042 | Debridement; skin, subcutaneous tissue and muscle, first 20 sq cm or less | Performed prior to closure or grafting when necrotic or infected tissue must be removed |
12001 | Simple repair of superficial wounds of face, ears, eyelids, nose, lips and mucous membranes; 2.5 cm or less | Used when straightforward primary closure of a simple wound is performed instead of reconstructive techniques |
14040 | Adjacent tissue transfer or rearrangement (e.g., flap), for trunk; defect 10 sq cm or less | Represents local flap closure techniques that may be chosen for defects requiring tissue rearrangement |
15271 | Placement of skin substitute graft, first 100 sq cm or less | Used when grafting with a skin substitute is performed to cover larger defects |
99213 | Office or other outpatient visit for the evaluation and management of an established patient, low to moderate severity | Common preoperative or postoperative E/M code reported with the procedure when a separate, billable visit is documented |
12032 | Intermediate repair of wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities; 2.6 cm to 7.5 cm | Used when closure requires layered intermediate repair techniques |