ED Coding and Reimbursement Alert

Understand the anatomical differences in the mouth repair codes to ethically maximize your revenue.

Wounds of the mouth can be tricky because of the sensitivity and delicate tissues involved, but also because of the cosmetic considerations of this highly visible area. The exact location and extent of the repair in question will determine which code to report for these common ED scenarios.

Todd Thomas, CPC, CCS-P, President of ERcoder, Inc. in Edmond, OK offers these tips for choosing the right code:

Most ED coders are very familiar with the repair or closure codes for suturing wounds of various anatomical sites and lengths. Based on the classification of the presenting mouth injury, you would choose a code from one of the following simple, intermediate, or complex groups to match the length of the repair, advises Thomas.

• 1201x -- Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes;
• 1205x -- Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes;
• 1315x-- Repair, complex, eyelids, nose, ears and/or lips.

Look to Anatomical Site for Repair Codes

However, CPT® instructs that for full thickness repairs, you should search the respective anatomical sites in the proper section of the book. Sometimes there is another code that more accurately describes the service provided.

For example, wounds in the vestibule of the mouth have their own codes, depending on length of the needed repair. The vestibule of the mouth, sometimes called the vestibulum ocris, is the portion of the oral cavity bounded on one side by the teeth and gums, or the residual alveolar ridges, and on the other side by the lips and cheeks. Repairs in this anatomical area should be reported with the following codes:

• 40830 -- Closure of laceration, vestibule of mouth; 2.5 cm or less
• 40831 -- Closure of laceration, vestibule of mouth; over 2.5 cm or complex

Pay attention to the anatomical details in the chart to capture the correct code

Don't Be Thrown By Vermillion Border

Perhaps the least understood mouth and lip repair codes are those that involve the vermillion border. This term refers to the line where the lips stop and the adjacent facial skin begins, usually easily determined by the change in color and texture, says Thomas. Coders will frequently focus on the vermillion border language in the code descriptor and lose sight of the fact that the code descriptor calls for a "full thickness" repair.

• 40650 Repair lip, full thickness; vermilion only
• 40652 Repair lip, full thickness; up to half vertical height

Caution: You would not report both codes 40650 and 40652 separately for a single repair. The code that best describes the repair that was performed should be reported. Code 40650 (Repair lip, full thickness; vermilion only) identifies the repair of a laceration that involves the full thickness of the lip and the vermilion border. Code 40652 (Repair lip, full thickness; up to half vertical height) involves a laceration or surgically created wound that extends through the full thickness of the lip, including the vermilion border, whose size extends up to one-half of the vertical height of the remaining lip area. The assigned RVUs and resulting payment in the chart below reflect the complexity of the more difficult repair and the compensation for these services:

Test Your Repair Savvy

Consider these two scenarios from Thomas to assess your repair coding know-how:

A 32-year-old male presents to the ED with a mouth injury after a bar fight. He claims he was punched in the face by a guy with a large ring. Examination shows a superficial 1.5cm tear in the upper lip, crossing the vermillion border.

A level 4 exam considers neurological damage and reveals no other significant cuts that require treatment and that his tetanus status is up to date. X-ray and head CT confirm no other facial fractures or brain injury.

On the claim you would report:

• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity)
• 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less)

Append modifier 25 to 99284

• Assign ICD9 code 873.43 (Other open wound of head; face, without mention of complication) to codes 99284 and 12011
• Assign E960.0 (Unarmed fight or brawl) to codes 99284 and 12011.

Rationale: Even though the wound did cross the vermillion border, it was not a "full thickness" injury required for reporting code 40650 (Repair lip, full thickness; vermilion only).

A woman presents with a serious injury from a neighbor's dog biting her face after she got too close. The dog reportedly bit the patient through the lower cheek and mouth, which then ripped clean through the full thickness of the vermillion border and half the height of the remaining lip as she pulled away from the dog and its weight was temporarily held by the bite grip.

In this case, you would report 40652 (Repair lip, full thickness; up to half vertical height) because the injury was a "full thickness" wound that extended through the vermillion border and at least half the vertical height of the remaining lip.