Otolaryngology Coding Alert
Anatomical Term Reveals Site of Lesion
Question: What is the correct coding for this situation? The physician injected the patient with 1 percent lidocaine and 1:100000 epinephrine.-The doctor used Betadine in the skin, and then in the gingivobuccal groove.-He used electrocautery to make an incision in the mucosa, and elevated the soft tissue off of the periosteum with a Freer. The physician identified the nerve, found a small nodule most consistent with neuroma, transected it, and closed with a 3-0 Chromic. Kentucky Subscriber Answer: The correct code would be 40812 (Excision of lesion of mucosa and submucosa, vestibule of mouth; with simple repair). The giveaway: A diagnosis would have been helpful to work with here, but the term "gingivobuccal groove" -- also known as the alveolobuccal groove -- gives away the general location in the vestibule of the mouth: between the lips and the teeth.(The use of a Freer periosteal elevator indicates the neuroma lies along the bone.) The physician merely sewed up the wound, so you-d indicate simple repair rather than 40814 (- with complex repair) or 40816 (- complex, with excision of underlying muscle).
Otolaryngology Coding Alert
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