Orthopedic Coding Alert

Question: Our orthopedist removed hardware from a patient's injury site, during which he removed the previous scar and reclosed the wound. Can we report a scar removal and reclosure code along with 20680 (Removal of implant; deep [e.g., buried wire, pin, screw, metal band, nail, rod or plate])?

Answer: You can bill for the scar revision, but the code you select depends on the orthopedist's technique. If the scar revision primarily involves the skin and subcutaneous tissue, it probably qualifies as a complex repair (13100-13153 select the appropriate code based on the scar's size). These codes include the scar excision.

To determine whether the repair was indeed complex, pay close attention to the operative report. Single-layer closures are generally simple (and therefore would be coded using 12001-12021). If the surgeon noted extensive wound cleansing or referred to a dual-layer closure, the wound repair was probably intermediate (12031-12057).

CPT considers extensive traumatic lacerations or avulsion revisions or repairs complex. If the operative report does not provide sufficient detail or if you are otherwise in doubt, check with the operating surgeon.

If the surgeon repairs the scar using z-plasty, rotation flap, or other grafting procedures, use a code in CPT's Adjacent Tissue Transfer or Rearrangement section (14000-14350). As with complex repairs, scar excision is included.