Otolaryngology Coding Alert

Plus, get a handle on the intricacies of the 4065X code set.

Last month, you were presented with a few helpful tips to get you on your way to coding lip repairs of various different laceration types and complexities. This month, you are going to put your skills to the test by tackling a clinical example head on.

Using this challenging example of a complex lip repair, you’ll be tasked with correctly interpreting the report and deciding between two lip repair code sets.

Consider Wound Site and Wound Type, Among Other Factors

Diagnosis: Patient has a lower lip 4 cm transverse laceration, 3 cm of which is through and through. There is a 1 cm inferior extension to the outside of the lip.

Report: The internal mucosa was approximated with 4-0 Vicryl in interrupted fashion and the vermilion border externally was approximated with 4-0 Prolene inferior to the vermilion border and as part of the laceration went through it, 4-0 Vicryl on the superior portions. Internal 4-0 Vicryls were also placed.

Consider: Using the article “Utilize these 2 Tips on your Way to Coding Intermediate, Complex Lip Repairs” in Otolaryngology Coding Alert Vol. 20, No. 7 as a guide, you should know that a through and through laceration diagnosis also qualifies as a full thickness diagnosis.

The most important distinction you must make when evaluating this report is determining which repair code set is appropriate. You may immediately consider one of three lip repair codes:

• 12052, Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm
• 12053, … 5.1 cm to 7.5 cm
• 13152, Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm.

Refresher: CPT^® makes clear distinctions as to what services are necessary in order for a coder to classify a repair as intermediate or complex:

• Intermediate repair: “An intermediate wound repair code includes the repair of a wound that, in addition to the requirements for simple repair, involves a layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia in addition to the skin (epidermal and dermal) closure. The single-layer closure of a heavily contaminated wound that requires extensive cleaning or removal of particulate matter also may also be considered an intermediate repair. Thus, an intermediate repair may be coded if the physician performed a layered closure or a single-layered closure that required extensive debridement.”
• Complex repair: “This includes repairs that require more than layered closure, such as scar revision, debridement of traumatic lacerations or avulsions, extensive undermining, stents, or retention sutures. It may also include excision of a scar requiring a complex repair or debridement and repair of complicated lacerations or avulsions.”

Next, take a look at the second lip repair code set you must consider:

• 40650, Repair lip, full thickness; vermilion only
• 40652, … up to half vertical height
• 40654, … over one-half vertical height, or complex.

Note Underlying Characteristics of 4065X Code Set

As you can see, the difference between these code sets is twofold. First, the 4065X code set requires, at the least, a full thickness laceration. Second, the 4065X code set forces you to consider the surgical involvement of the vermillion border.

“The exact location and extent of the repair in question will determine which code to report for the lip repair,” says Ronda Tews, CPC, CHC, CCS-P, AAPC Fellow, Associate Consultant at Acevedo Consulting Incorporated in Delray Beach, FL. “CPT^® instructs that, for full thickness repairs, you should reference the respective anatomical sites in the proper section of the CPT^® book. CPT^® code 40650 would be the correct anatomical section for a full thickness lip repair that involves the vermillion border. If documentation supports vermilion involvement, and less than a ‘full thickness’ wound repair, then refer back to your intermediate or complex repair codes,” Tews explains.

Despite the fact that this example involves a laceration crossing the vermillion border, some coders may assume that a through and through laceration automatically requires complex repair code 13152, rather than a code from the 4065X code set.

Beware: “You cannot assume that a repair of a through and through lip laceration will automatically be coded as a complex repair,” states Jennifer M. Connell, CPC, COC, CENTC, CPCO, CPMA, CPPM, CPC-P, CPB, CPC-I, CEMA, owner of E2E Health Solutions in Victoria, Texas. “Depending on the nature of the repair, a through and through lip repair could be coded with a repair code from 40650-40654, or with an intermediate or complex repair code, or even possibly an adjacent tissue transfer or rearrangement code,” Connell explains.

Don’t Let 4065X Code Descriptions Confuse You

Since you know that a through and through laceration is, by definition, a full thickness laceration, you can conclude that the 4065X code set is appropriate to code in this example. The next step in the process is determining which 4065X code is appropriate. An article in Volume 26, Issue 11 of the November 2016 CPT^® Assistant helps to explain the underlying differences between the codes:

“Note that code 40650 describes a repair of the full thickness of the lip that does not cross the vermillion border. If the wound repair does cross the vermillion border and reaches into the skin surrounding the lips, code 40652, Repair lip, full thickness; up to half vertical height, or code 40654, Repair lip, full thickness; over one-half vertical height, or complex, may be reported instead. If the wound requiring repair is not full thickness, then the appropriate code from the Repair (Closure) subsection of the CPT^® code set may be reported, such as code 12011, Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less.”

So, even though the code descriptions in 40652 and 40654 do not reference the vermillion border, these codes should only be used for full thickness wounds that extend beyond the vermillion border. On the same note, you shouldn’t consider 40650 since the wound does cross the vermillion border. The only way in which you would not want to consider 40652 and 40654 would be if the length of the wound was not at least half of the vertical height of the lip. In the example above, a 4 cm laceration is undoubtedly more than one half the vertical height of the lower lip. Therefore, you can conclude that 40654 is the correct code in the example provided.