ED Coding and Reimbursement Alert

Question: One of our physicians treated a patient who had a vertical linear laceration measuring 2 cm on the skin surface in the philtrum. The laceration extended into the vermilion border and had a Y-shaped component. The physician anesthetized the wound and then, using a running horizontal suture, repaired the laceration up to the vermilion border. Using a simple horizontal purse-string mattress suture, the doctor pulled the Y-shaped wound back into position. When assigning a code, I saw that CPT 40650 (Repair lip ...) is for "full thickness," but to me this seems more difficult than a simple lip repair (12011). At the same time, this procedure doesn't sound like layered closure, so intermediate repair doesn't seem appropriate either. Which code should I use?

Pennsylvania Subscriber

Answer: This procedure doesn't qualify as a complex procedure because there was no debridement, undermining, or the creation of a defect. The related issue of whether the procedure qualifies as intermediate is open to interpretation.

The initial portion of the closure, when the physician used a running horizontal mattress suture, is an example of a very sophisticated (but non-"complex") technique for a single layer repair. The initial portion of the repair could have been done with simple interrupted sutures. Running sutures are generally done for the physician's convenience because they don't require the doctor to tie additional knots and cut the suture multiple times.

Running repairs are not very common in the ED because the wounds presented there usually run the danger of contamination. The very tight closure resulting from a running repair doesn't allow any wound drainage, increasing the risk of infection.

The second part of your description refers to a single fancy stitch used to approximate the vermilion border, where the lip tissue meets the face skin. In this case, the technique of a "horizontal purse-string mattress" is beneficial and may afford better approximation of the tissues for the best possible cosmetic result. However, the corner could have been closed by two simple interrupted sutures.

Some experts think that approximation of the vermilion border even though it is non-layered qualifies as intermediate since it is a very cosmetically sensitive area that requires exact suture placement. Most agree, however, that this definition falls outside of the current CPT definitions of "intermediate," and coding it as such is a convention adopted by some ED groups to recognize the extra work involved. However, ask your local payers for their ruling on this issue.