General Surgery Coding Alert

Question: What is the proper code to report scar revision on a mastectomy site?


Louisiana Subscriber

Answer: Your best option is likely the complex repair codes 13100-13102 (Repair, complex, trunk ...). The text in the "wound repair" portion of CPT's surgery section introduction specifically includes scar revision as an appropriate reason to report wound repairs. In addition, the text remarks that complex repairs require "more than layered closure."

You should select an appropriate code from 13100-13102, depending on the length of the wound - whether curved, angular or stellate - in centimeters, that the surgeon repairs. You may report as many units of +13102 (... each additional 5 cm or less [list separately in addition to code for primary procedure]) as required to describe the entire length of the wound.

You should include simple exploration, if required, as part of wound repair. You should also include excision of the scar (creation of the defect).

For example, if the surgeon revises a scar at the site of a previous mastectomy that measures 17.5 cm, you should claim 13101 (Repair, complex, trunk; 2.6 cm to 7.5 cm) plus 13102 x 2.