General Surgery Coding Alert

Question: For a patient requiring revision of a scar on his left leg, our surgeon excised a 19 cm strip of skin containing scar tissue and performed layered closure. Should we use a benign lesion excision code for this service?

Indiana Subscriber

Answer: No, you should not use a benign lesion excision code for this service, either alone or in combination with intermediate or complex closure codes. Instead, you should list a complex wound repair code for the service.

Specifically: For complex repair of a 19 cm defect on the leg, list 13121 (Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm) for the first 7.5 cm, plus +13122 x 3 (... each additional 5 cm or less [List separately in addition to code for primary procedure]) for the remaining 11.5 cm.

Excision included: You should not use a benign lesion code (such as 11406, Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter over 4.0 cm) to separately charge for the excising the scar, even though CPT® instruction allows you to bill complex closure in addition to benign lesion excision.

Here's why: Creating a defect by excising the scar tissue is actually part of what makes this service a complex closure procedure. CPT® instruction states that complex repair "includes the repair of wounds requiring more than layered closure, viz., scar revision... Necessary preparation includes creation of a limited defect for repairs..."

Bottom line: The scar excision plus the layered closure justifies selecting the complex wound repair codes.