Kevinph84
Guest
My Fellow Coders,
I have a question with the below scrubbed operative report. The surgeon performed scar revision on the outside and inside of the lip. The provider also removed gravel from inside the lip. My thoughts are to use CPT code 13151 for the external scar of the lip and CPT code 40804 for the removal of foreign body from inside the mouth. Would you report the scar revision for inside the mouth seperately? Would you consider it an inclusive component to the foreign body removal? If you would report this seperately, what code do you think would best support this service? Thank you all for your help.
PROCEDURE:EXCISION AND REVISION OF SCARS OF THE LOWER LIP VERMILION BORDER AND LOWER LIP MUCOSA WITH REMOVAL OF FOREIGN BODY.
OPERATIVE PROCEDURE: Infiltration of the mental nerves first and then infiltration directly with local anesthetic. Initial attention was to the anterior which is prepped and draped in the sterile manner, central lower lip segment measuring about 2 cm in length, this excise had a vertical and a transverse component to this. This was completely excised with a #15 blade scalpel. Release of all scar tissue was elevated from skin and subcutaneous tissues overlying the orbicularis oris muscle anteriorly and inferiorly. We then closed after hemostasis with bipolar with inverting 5-0 PDS and cuticular 5-0 plain catgut. Attention was then turned to the intraoral aspect where itself there was a large scar with particular matter. This turned out to be the case with a fair amount of what appeared to be black gravel in the lower lip submucosal tissue. After excision with #15 blade scalpel through the skin and subcutaneous tissues around the old scar, we released the mucosal and submucosal soft tissues from the underlying muscle with dissection. This is quite difficult and has lot of scar. Hemostasis was with bipolar. Closure with inverting 5-0 Vicryl and running 4-0 chromic. The length of this excision was also about 2.5 cm. Antibiotic ointment placed. She tolerated this well and was transferred to recovery in stable condition.
I have a question with the below scrubbed operative report. The surgeon performed scar revision on the outside and inside of the lip. The provider also removed gravel from inside the lip. My thoughts are to use CPT code 13151 for the external scar of the lip and CPT code 40804 for the removal of foreign body from inside the mouth. Would you report the scar revision for inside the mouth seperately? Would you consider it an inclusive component to the foreign body removal? If you would report this seperately, what code do you think would best support this service? Thank you all for your help.
PROCEDURE:EXCISION AND REVISION OF SCARS OF THE LOWER LIP VERMILION BORDER AND LOWER LIP MUCOSA WITH REMOVAL OF FOREIGN BODY.
OPERATIVE PROCEDURE: Infiltration of the mental nerves first and then infiltration directly with local anesthetic. Initial attention was to the anterior which is prepped and draped in the sterile manner, central lower lip segment measuring about 2 cm in length, this excise had a vertical and a transverse component to this. This was completely excised with a #15 blade scalpel. Release of all scar tissue was elevated from skin and subcutaneous tissues overlying the orbicularis oris muscle anteriorly and inferiorly. We then closed after hemostasis with bipolar with inverting 5-0 PDS and cuticular 5-0 plain catgut. Attention was then turned to the intraoral aspect where itself there was a large scar with particular matter. This turned out to be the case with a fair amount of what appeared to be black gravel in the lower lip submucosal tissue. After excision with #15 blade scalpel through the skin and subcutaneous tissues around the old scar, we released the mucosal and submucosal soft tissues from the underlying muscle with dissection. This is quite difficult and has lot of scar. Hemostasis was with bipolar. Closure with inverting 5-0 Vicryl and running 4-0 chromic. The length of this excision was also about 2.5 cm. Antibiotic ointment placed. She tolerated this well and was transferred to recovery in stable condition.