There are many different ways that scar revisions can be coded, and distinguishing among them can be confusing for some
otolaryngology coders . Two services are involved excision and repair and, depending on the situation, one or the other, or both, may be payable services. A well-informed coder can properly code this procedure by identifying the patient criteria.
For example, if the scar is excised and only a simple repair is required, only the lesion (scar) removal is coded. If complex or intermediate repair is required, the repair and excision are coded separately, whereas if the repair requires a flap (typically, a form of adjacent tissue transfer), only the repair is billed.
In addition, otolaryngologists and their coders need to be able to determine whether the service is medically necessary or cosmetic. Most carriers do not pay for cosmetic procedures.
Medically Necessary or Cosmetic?
If the service performed is just the revision of an ugly scar, that will be considered cosmetic by most carriers, says Margaret Hickey, MS, MSN, RN, an independent coding and reimbursement specialist in Louisiana, and immediate past-president of the Society of Otorhinolaryngology and Head-Neck Nurses. What is considered cosmetic on an adult often may be deemed medically necessary for a child, Hickey adds.
The key thing to determine whether the procedure will be judged as cosmetic is: Does the scar interfere with function? If it does, the procedure may be payable; if not, it likely will be considered cosmetic.
If the patient had a malignancy removed, excising the scar is considered aftercare with plastic surgery, and most carriers will pay for that if you provide supporting documentation, says Melissa Pointer, CPC, billing manager with the department of Otolaryngology at the University of Arkansas in Little Rock. On the other hand, if you had a lipoma taken off and you didnt like how it looked, carriers wouldnt pay for that.
In adults, scars that impede function usually occur around the eyes or mouth. For example, a patient with a basal cell carcinoma on the lip may have the carcinoma removed, and the scar formed from that excision impedes the patients speech and eating and therefore the removal is medically necessary.
The otolaryngologist decides to remove the scar, which is 2 centimeters long. The procedure is a benign lesion excision, and in this case, because the scar is on the lip and is 2 centimeters long, code 11442 (excision, other benign lesion [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm) should be used.
Wound Repair Coding
To repair a wound formed by an excision, the otolaryngologist likely will perform an intermediate or complex closure, or an adjacent tissue [...]
