Otolaryngology Coding Alert

Question: An otolaryngologist repairs 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: One possible solution is: 
  40527 - lip excision                        

 925. 1 - Crushing injury of face and scalp
  11012-59 - hard palate debridement separate from repair  

 802.3x - Open mandible fracture
  11011-59 - eye socket debridement separate from repair 
  11010-59 x 2 - lip, facial debridement separate from repair 

 802.3x - Open mandible 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 an otolaryngologist 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 the otolaryngologist debrides the skin and subcutaneous tissues, assign 11010 (Debridement including removal of foreign material associated with open fracture[s] and/or dislocation[s]; skin and subcutaneous tissues). For debridement that includes muscle fascia and muscle, select 11011 (... skin, subcutaneous tissue, muscle fascia, and muscle). If the otolaryngologist debrides down to the bone, report 11012 (... skin, subcutaneous tissue, muscle fascia, muscle, and bone).

Try this: You will need modifier -59 (Distinct procedural service) on the lip debridement code. If the otolaryngologist debrides a different part of the lip that is unrelated to the flap, append modifier -59 (Distinct procedural service) to the appropriate debridement code. The modifier informs the carrier that the surgeon performed debridement at a separate site from the repair. Thus, the insurer should not bundle the debridement code into the repair 40527 (Excision of lip; full thickness, reconstruction with cross lip flap [Abbe-Estlander]).

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 the otolaryngologist performed the hard palate, eye socket, and facial debridements on separate sites from the flap repair. Using modifier -59 tells the payer that it should not include the debridements in the site preparation (40527).