Otolaryngology Coding Alert

There are many different ways that scar revisions can be coded, and distinguishing among them can be confusing for some otolaryngology coders . Two services are involved excision and repair and, depending on the situation, one or the other, or both, may be payable services. A well-informed coder can properly code this procedure by identifying the patient criteria.

For example, if the scar is excised and only a simple repair is required, only the lesion (scar) removal is coded. If complex or intermediate repair is required, the repair and excision are coded separately, whereas if the repair requires a flap (typically, a form of adjacent tissue transfer), only the repair is billed.

In addition, otolaryngologists and their coders need to be able to determine whether the service is medically necessary or cosmetic. Most carriers do not pay for cosmetic procedures.

Medically Necessary or Cosmetic?

If the service performed is just the revision of an ugly scar, that will be considered cosmetic by most carriers, says Margaret Hickey, MS, MSN, RN, an independent coding and reimbursement specialist in Louisiana, and immediate past-president of the Society of Otorhinolaryngology and Head-Neck Nurses. What is considered cosmetic on an adult often may be deemed medically necessary for a child, Hickey adds.

The key thing to determine whether the procedure will be judged as cosmetic is: Does the scar interfere with function? If it does, the procedure may be payable; if not, it likely will be considered cosmetic.

If the patient had a malignancy removed, excising the scar is considered aftercare with plastic surgery, and most carriers will pay for that if you provide supporting documentation, says Melissa Pointer, CPC, billing manager with the department of Otolaryngology at the University of Arkansas in Little Rock. On the other hand, if you had a lipoma taken off and you didnt like how it looked, carriers wouldnt pay for that.

In adults, scars that impede function usually occur around the eyes or mouth. For example, a patient with a basal cell carcinoma on the lip may have the carcinoma removed, and the scar formed from that excision impedes the patients speech and eating and therefore the removal is medically necessary.

The otolaryngologist decides to remove the scar, which is 2 centimeters long. The procedure is a benign lesion excision, and in this case, because the scar is on the lip and is 2 centimeters long, code 11442 (excision, other benign lesion [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm) should be used.

Wound Repair Coding

To repair a wound formed by an excision, the otolaryngologist likely will perform an intermediate or complex closure, or an adjacent tissue transfer. If all that is required is a simple closure, no repair code would be billed. If an intermediate closure (which CPT defines as requiring 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) is performed, code 12051 (layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes, 2.5 cm or less) should be used. If the wound is more serious and requires complex repair (i.e., requiring extensive undermining, stents or retention sutures), code 13151 (repair, complex, eyelids, nose, ears, and/or lips; 1.1 cm to 2.5 cm) should be billed.

As with the excision, the correct intermediate or complex repair code is determined by the part of the body and the size (length) of the repair.

If the scar excision leaves a deficit that is too large or too deep to perform a complex repair, however, the otolaryngologist may need to perform some form of adjacent tissue transfer, says Suzanne Yee, MD, a facial plastic surgeon in Little Rock, Ark.

Adjacent tissue transfers often are referred to as skin flaps and, according to CPT, include Z-plasty, W-plasty, V-Y plasty, rotation flaps, advancement flaps and double pedicle flaps. Unlike repairs, the correct code for this procedure is not determined by the length of the wound but rather by the area of the defect (in square centimeters) and its location on the body.

The decision about whether to use a complex repair or an adjacent tissue transfer depends on the size and depth of the lesion, says Yee. In a complex repair, tissue is pulled together and sutured. If there isnt enough available tissue, a Z-plasty, for example, which makes a Z-shaped incision into the skin adjacent to the wound and forms a Z-shaped flap that is stretched over the wound while the other side of the skin remains attached to the body and helps re-vascularize the repaired wound area, should be used.

For example, a tissue transfer might be used to repair a scar formed by a brown recluse spider bite, which causes skin necrosis, Yee says. You end up with a hole in the skin wherever the spider bites, Yee says, and after it heals, the scar is removed, and if its big enough you may need to do a tissue transfer to close it. If its very large and there isnt enough tissue adjacent to it, you would do a tissue transfer, Yee says, noting that with tissue transfers, you have to undermine more and make more cuts to create more angles than would be required for a complex closure.

Tissue transfers also may be required for scars that occur after several other problems, including cancer, trauma, car accidents or dog bites. In all these situations, a patient may return for scar revision because the original excision has not closed properly.

Excision of Lesion Included in Tissue Transfer

Unlike intermediate or complex closures, the removal of a lesion cannot be billed if an adjacent tissue transfer also was performed because it is included in the tissue transfer procedure.

For example, a 12-year old child is attacked by a dog and has large bites on the cheek. The wounds are debrided and closed by complex or intermediate repair. Subsequently, the child presents with an 8 centimeter x 3 centimeter scar on cheek and parents want the scar removed. In all likelihood, the insurer will pay for the procedure because the scar is the result of a dog bite. (The same would apply for a patient who had been in a car accident, or who had cancer.)

After the scar is excised and debrided, the otolaryngologist performs an adjacent tissue transfer to repair the wound.

This procedure would be coded 14041 (adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30 sq. cm). The excision of the scar should not be billed, as it is included in the tissue transfer.

Like the repair codes, adjacent tissue transfer codes are organized according to the size of the defect (in square centimeters) and the location of the defect on the body. A defect that measures more than 30 sq cm, however, is coded using 14300 (adjacent tissue transfer or rearrangement, more than 30 sq cm, unusual or complicated, any area) regardless of its location on the body.

Note: Glenn Knox, MD, an otolaryngologist in Jacksonville, Fla., and Teresa Thompson, an independent otolaryngology coding and reimbursement specialist in Sequim, Wash., also contributed to this story.