Oral Surgery Coding & Reimbursement Alert

Reader Question:

Don't Report Debridement Prior to Flap Repair Separately

Published on Tue Feb 23, 2016

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Question: Our surgeon recently repaired a gunshot victim’s facial and lip wounds. We are using 40527 for an Abbe-Estlander lip switch flap.The surgeon also performs wound debridement of the hard palate and eye socket, as well as facial and lip wounds. Can we charge separately for the debridements? If so, what codes should we use?

Washington Subscriber

Answer: You can look towards reporting the following CPT^® and ICD-10 diagnosis codes for the scenario that you have described:

40527 (Excision of lip; full thickness, reconstruction with cross lip flap [Abbe-Estlander]) for the lip excision
S07.0xxA - Crushing injury of face, initial encounter
11012-59 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation [e.g., excisional debridement]; skin, subcutaneous tissue, muscle fascia, muscle, and bone) for the hard palate debridement separate from repair
S02.609B - Fracture of mandible, unspecified, initial encounter for open fracture
11011-59 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation [e.g., excisional debridement]; skin, subcutaneous tissue, muscle fascia, and muscle) for the eye socket debridement separate from repair
11010-59 x 2 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation [e.g., excisional debridement]; skin and subcutaneous tissues) for the lip, facial debridement separate from repair
S02.609B - Fracture of mandible, unspecified, initial encounter for open fracture

Caveat: The above claim assumes that the debridements are not related to the flap repair. You may report debridement that is unrelated to the flap repair.

In your example, this seems to be the case. The hard palate and eye socket debridements do not appear to relate to the lip flap.

Watch out: You shouldn’t bill for debridement that your surgeon performs only to prepare the flap. Site preparation is incidental to site reconstruction, according to CPT^® guidelines.

Debridement: The injuries probably involve fractured bones. Therefore, you should report debridement codes 11010-11012.

Choose the appropriate debridement with foreign material removal code based on the debridement’s depth.

If your surgeon debrides the skin and subcutaneous tissues, report the procedure with the CPT^® code 11010. For debridement that includes muscle fascia and muscle, select 11011. If your surgeon debrides down to the bone, report 11012.

Try this: You will need modifier 59 (Distinct procedural service) on the lip debridement code. If your clinician debrides a different part of the lip that is unrelated to the flap, append the modifier 59 to the appropriate debridement code. The modifier informs the carrier that your surgeon performed debridement at a separate site from the repair. Thus, the insurer should not bundle the debridement code into the repair 40527.

You will also have to use modifier 59 with the other debridement codes. Because the debridement codes are not site specific, the insurer has no way of knowing that your surgeon performed the hard palate, eye socket, and facial debridements on separate sites from the flap repair. Using the modifier 59 tells the payer that it should not include the debridements in the site preparation (40527).