General Surgery Coding Alert

Question: How should we report a” through and through” laceration repair of the lip? Report states 2.5-3 cm mucosal portion repaired, and 2.5-3 cm vermillion border repaired with extensive cleaning and retention sutures.

Kansas Subscriber

Answer: Based on your description, the best code choice is 40654 (Repair lip, full thickness; over one-half vertical height, or complex).

Often, you’ll code wound closures of the lips using one of the following codes, based on complexity:

• 1201x — Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes
• 1205x — Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes
• 1315x — Repair, complex, eyelids, nose ears and/or lips.

However, CPT^® instructs that for certain injuries such as full thickness repairs, you should search the respective anatomical sites in the proper section of the book. Sometimes there is another code that more accurately describes the service provided.

In this case, the most accurate code is 40654, because it’s a full-thickness, complex layered repair requiring extensive cleaning and retention sutures.