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Oral Surgery Coding & Reimbursement Alert

You Be the Coder:

Base Laceration Code Choice on Length and Complexity of Closure

Published on Fri Mar 27, 2015

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, our clinician irrigated the area to ensure there was no debris. Then, he used sutures to close a 2.2 cm wound. Notes indicated a level-three E/M preceded the repair. I reported 40831 and received a denial. What happened?

New Orleans Subscriber

Answer:
You received a denial as the length of the wound was not adequate to report 40831 (Closure of laceration, vestibule of mouth; over 2.5 cm or complex). Also, the wound closure was not complex enough for you to report a higher level code. Instead, you can report the following codes for the procedure and the evaluation that your clinician carried out:
  • 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 patients, 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 or other qualified healthcare professional 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 palate uncomplicated) appended to 40830 and 99213 to represent the patient’s injury. When you begin using ICD-10 codes, you can switch to reporting S01.512A (Laceration without foreign body of oral cavity, initial encounter) instead of 873.65.
Tip: In order to report 40831, 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.

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