Otolaryngology Coding Alert

Even though medical necessity is a driving force in receiving reimbursement for scar revisions, the level of repair ultimately determines the appropriate coding. So, follow the coding guidelines for three methods to ensure that you capture all the otolaryngologist's billable procedures.

Otolaryngologists and coders must first determine whether the scar revision is medically necessary. Most payers will not pay for cosmetic procedures. If a scar impedes function, insurers will probably cover the service. If a patient requests a scar removal because he or she just doesn't like how it looks, however, the payer will likely refuse coverage.

Most payers consider scar revision after an otolaryngologist removes a malignancy necessary aftercare and will usually cover these services, provided you include supporting documentation. For instance, a patient has a basal cell carcinoma on his lip, and the carcinoma is removed, leaving a scar. The carrier will likely cover the scar removal because the scar resulted from a malignancy.

When the otolaryngologist excises a scar that requires only a simple repair, report the appropriate lesion removal code based on the lesion's size. "Measure the size of the lesion at the widest dimension," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. You cannot add lesion codes together. "Bill each lesion removal separately," she says, which translates to coding each scar separately.

In addition, CPT further categorizes the lesion excision codes by the lesion's type benign or malignant and location, says Julie Robertson, CPC, an otolaryn-gology coding and reimbursement specialist for University ENT Specialists in Cincinnati. A scar falls into the category of a benign lesion.

For example, the otolaryngologist removes a painful 2.2-centimeter scar from the left side of a patient's nose. In this case, you should report 11443 (Excision, other benign lesion [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm). The correct code is selected from the excision benign lesions section (11400-11471), based on the lesion's location and size. "These codes are for lesions of the skin and subcutaneous tissues only," Robertson says.

Excision also includes simple closure, according to CPT's introductions to the excision benign lesions and excisions malignant lesions sections. Therefore, when an excision wound requires a simple closure, you should assign the appropriate excision code only. CPT bundles simple repair into the excision code.

For a wound that requires a complex or intermediate repair, report the repair and the excision. Unlike lesion codes, which are never added together, you should always add closure codes of like kind together. Combine multiple closures the otolaryngologist performs on the same body area and at the same depth, Callaway says. Do not combine closures of different classifications, such as intermediate and complex, even if the wounds occur on the same anatomic site.

For an intermediate repair, report intermediate repair codes 12031-12057. Documentation of these repairs requires "layered closure of one or more of the deep layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure," CPT states.

Consider the above example of the patient who has a painful scar repaired. Suppose the wound is deeper and requires an intermediate repair. You should assign 12051* (Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less) based on the size and location of the wound. In addition, report the excision 11423. Report the repair code first followed by the excision code, because the repair code (12051, 5.74 nonfacility relative value units [RVUs]) has more RVUs than the excision code (11423, nonfacility 5.36 RVUs).

Remember that the documentation must reflect the precise location, size and depth of the repair to aid the coder in appropriate code selection, Robertson says.

If the wound in the above scenario requires complex repair, report 13151 (Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm) and 11423. Complex repairs involve reconstructive procedures and complicated wound closure, as defined in CPT. Once again, list the repair code first and then the excision code, because 13151 (9.8 nonfacility RVUs) has more RVUs than 11423.

Sometimes, the scar excision is so severe that the physician must use an adjacent tissue transfer, such as a Z-plasty, to close the wound. Trauma or injuries, such as car accidents, animal bites and cancer, may leave a wound that is too deep or too large, making a complex repair insufficient. The otolaryngologist may then perform a tissue transfer or skin flap (14000-14300). If the defect is repaired during the same session as the excision, codes 14000-14300 include the lesion excision, Robertson says. Therefore, you should assign the appropriate adjacent tissue transfer code only.

Unlike the lesion and repair codes, which are measured by centimeters, these codes are defined by area and per defect.

For example, during a car accident, the windshield shatters leaving glass shards in a patient's cheeks. Intermediate and complex repairs close the wounds. The patient requests that an otolaryngologist repair the 5- by 2-centimeter scar on his cheek. After excising and debriding the wound, the otolaryngologist performs a tissue transfer to repair the site.

Based on the square area of the scar, 10 centimeters, select 14040 (Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less). Do not bill for the excision because it is included in the tissue transfer.