Wiki Lower lipesion

[paula f3]

Op note read as follows
The patient was taken to the OR and after adequate general anesthesia, the patient was prepped and draped in the usual sterile manner. I marked the area and marked the vermilion-cutaneous border to make sure that lined up. A wedge incision was taken down into the muscle. It was sent for frozen section and the diagnosis was scar. I closed the defect, basically mobilizing medial and lateral flaps in a wedge -type fashion. The subq tissue was closed using 4-0 Vicryl and the skin was closed using 5-0 nylon, lining up the cutaneous border first and then closing the skin in the vermilion with 5-0 nylon and l suture of 5-ochromic was used.

not sure as to what code to use looking at 40525
Please help
Thank you
Paula

 

[nsteinhauser]

The lay descrtiption for 40525 reads:
The physician removes a full thickness portion of the lip with local flap reconstruction. A "V" incision may be made around the lesion and through the full thickness of the lip. The lesion and surrounding tissues are removed. A local skin flap is incised and advanced to the site of the surgical wound and sutured into place with layered closure.

The lay description for 40510 reads:
The physician removes a portion of the lip using a transverse wedge technique. Incisions are made perpendicularly through the skin and mucosa and a wedge of the lip with surrounding tissue is removed. The physician extends the incisions below the surgical wound and advances the tissue flaps. The incisions are sutured primarily.

Since it states in the operative note that it was a wedge incision and a separate incision wasn't made to create a flap to advance over the site, I think you may want to look at 40510. Hope this helps.