Medicare Compliance & Reimbursement

Question: An established patient reported to our practice with a cut in the vestibule of the mouth; it was bleeding moderately. The patient reported that he bit down on a lobster shell by mistake and cut the roof of his mouth. After stopping the bleeding, the physician irrigated the area to ensure there was no debris. Then, she used sutures to close a 2.2 cm wound. Notes indicated a levelthree E/M preceded the repair. I reported 40831 and received a denial. What happened?

Answer: The claim didn't fly because the wound was not long or complicated enough to justify your code choice. When you resubmit the claim to your payer, report the following codes:

• 40830 (Closure of laceration; vestibule of mouth; 2.5 cm or less) for the mouth repair

• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of 3 components...) for the E/M

• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99213 to show that the E/M visit was a separate service from the repair

• 873.65 (Open wound of head; internal structures of mouth, without mention of complication; palate) appended to 40830 and 99283 to represent the patient's injury.

Explanation: In order to report 40831 (... over 2.5 cm or complex), the wound must exceed 2.5 cm or the closure must be complicated.

The use of irrigation does not increase the complexity of this procedure to the level of 40831, so the irrigation alone wouldn't have warranted that code.

If the patient's vestibule had suffered extensive tissue damage, crushing, or required complex closure (such as retention sutures), then you may have been able to report 40831.