Otolaryngology Coding Alert

Question: Under the exam heading, the surgeon documents the following procedure: Complex repair upper lip measuring 1.1. However, the operative note states thefollowing:

A #15 blade was used to incise the previously made lines, including both the lesion and the margins as well as inferior and superior burow triangles. The lesion was sent to path. Hemostasis was achieved with bipolar cautery. The wound was widely undermined with a #15 blade for 1 cm in all directions. The wound was closed in a multilayered fashion with deep inverted sutures.

Can I code as 13151 since wide undermining constitutes a complex repair?

Minnesota Subscriber

Answer: First, you need to know what CPT^® constitutes as a complex repair. The CPT^® manual defines a complex repair as "the repair of wounds requiring more than layered closure, scar revision, debridement, (e.g., traumatic lacerations or avulsions), extensive undermining, stents, or retention sutures. It may include creation of the defect and necessary preparation for repairs or the debridement and repair of complicated lacerations and avulsions. Complex repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions, excisional preparation of a wound bed (15002-+15005) or debridement of an open fractur or open dislocation."

Based on this definition, you could certainly classify a wide undermining technique as a complex repair. However, extensive undermining alone is not enough to get you to code 13151 (Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm). Rather, the documentation must also state that the wound measures 1.1 cm or greater. In this case, the operative report does not match the exam header. Since the physician only documents a 1 cm wound in the operative report, you must use this as a final reference. Rather than using 13151, you should opt for the intermediate repair code 12051 (Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less).

It might, however, be in your best interest to confirm the .1 cm size discrepancy with the physician. However, assuming the size discrepancy remains true, you should always follow the rule that size trumps technique. In this case, a complex repair technique doesn't matter if the wound doesn't meet the criteria for the complex repair code.