ED Coding and Reimbursement Alert

Depth of the injury and closure method chosen will drive correct code choice

Due to geographic and/or economic barriers, some emergency physicians no longer have on-call coverage for some of the medical specialties that they had in the past. Many emergency physicians are performing procedures in the ED that were historically sent to the operating room or performed in the ED by an on-call specialist. As a result, ED coders must become familiar with CPT^® codes that weren’t traditionally reported by emergency physicians.

One such example is CPT^® code 40650 (Repair lip, full thickness; vermilion only).

This procedure has traditionally been performed by the plastic surgeon, but ED coders are more frequently finding documentation that this service has been performed by the emergency physician. While it’s important for the coder to recognize when this procedure has been performed by the emergency physician and apply the appropriate code, it is just as important for a coder to recognize when the procedure performed by the emergency physician does not rise to the level described by this code, says Todd Thomas, CPC, CCS-P, President of ER coder in Edmond, OK.

“I have seen charts were this code accurately described the procedure performed by the emergency physician. But most of the time procedure notes that reference the vermilion border are more accurately coded with the 120xx repair (closure) series codes,” Thomas adds.

“In my work as an auditor I have seen several instances where the coder has assigned 40650 but the documented description of the patient’s injury and/or the description of the procedure performed by the emergency physician did not support the CPT^® description of this code. Coders will frequently focus on the vermilion border (the anatomic line where the colored fleshy lip tissue meets the adjacent facial skin) language in the code descriptor and lose sight of the fact that the code descriptor specifies a full thickness repair. Single layer or simple repairs that cross over the vermilion border do not necessarily rise to the level required to report 40650,” Thomas warns.

Keep in mind that just because a laceration repair does cross into the vermilion border, if it does not also involve the depth and complexity of the injury, it will not meet the requirements of a full thickness laceration described by CPT^® code 40650. Instead, the most accurate code to report for these is one from the 1201x series. When asked about the use of this code for a single repair that extends beyond the vermilion, CPT Assistant^® advised “Code 40650, identifies the repair of a laceration that involves the full thickness of the lip and the vermilion border.”

Some coders and physicians feel that approximation of the vermilion border, even though it is non-layered qualifies as an intermediate repair since it is a very cosmetically sensitive area that requires exact suture placement. However, most coding experts agree that this definition falls outside of the current CPT^® definitions of “intermediate,” Thomas says.

Consider the Coder’s Desk Reference explanation of the procedure as a guide, Thomas says. “The physician repairs a full sickness laceration of the lip. The tissues of the vermilion border are closed with layered sutures.”

Closely related to the vermilion border repair code are; 40652 (Repair lip, full thickness; up to half vertical height) and 40654 (Repair lip, full thickness; over one-half vertical height, or complex). These codes represent full thickness lacerations that extend past the vermillion border into the patient’s lip.

As the anatomy of each patient is unique, the mid-point of the lip is not a predetermined measurement but is specific to the individual patient. Imagine a line that reflects the language in the CPT^® code descriptor detailing “up to one half” or “over one half the vertical height” of the  laceration needing repair for either the upper or lower lip as the case presentation specifies. That visualization could help you determine whether code 40652 or 40654 is indicated.

Note: These codes include the repair of the vermillion border and would not be reported in addition to 40650, Thomas explains.