Outpatient Facility Coding Alert

Published on Tue Jun 18, 2013 PDF

Question: One of the physicians in our urgent care center reported a 2.5-3 cm mucosal portion repair and “vermillion” border repair (also 2.5-3 cm). How should we code this?

Kansas Subscriber

Answer: Wounds of the mouth can be tricky because of the sensitivity and delicate tissues involved, but also because of the cosmetic considerations of this highly visible area. The exact location and extent of the repair in question will determine which code to report for these common ED or urgent care scenarios.

Most urgent care coders are very familiar with the repair or closure codes for suturing wounds of various anatomical sites and lengths. Based on the classification of the presenting mouth injury, you would frequently choose a code from one of the following simple, intermediate, or complex groups to match the length of the repair.

• 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.

Caveat: 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.

For example, wounds in the vestibule of the mouth have their own codes, depending on length of the needed repair. The vestibule of the mouth is the portion of the oral cavity bounded on one side by the teeth and gums, or the residual alveolar ridges, and on the other side by the lips and cheeks. Repairs in this anatomical area should be reported with the following codes:

• 40830 — Closure of laceration, vestibule of mouth; 2.5 cm or less
• 40831 — Closure of laceration, vestibule of mouth; over 2.5 cm or complex

Pay attention to the anatomical details in the chart to capture the correct code.

Perhaps the least understood mouth and lip repair codes are those that involve the vermillion border. This term refers to the line where the lips stop and the adjacent facial skin begins, usually easily determined by the change in color and texture, Coders will frequently focus on the vermillion border language in the code descriptor and lose sight of the fact that the code descriptor calls for a “full thickness” repair.

• 40650 — Repair lip, full thickness; vermilion only
• 40652 — Repair lip; up to half vertical height

You would not report both codes 40650 and 40652 separately for a single repair. The code that best describes the repair that was performed should be reported. Code 40650 identifies the repair of a laceration that involves the full thickness of the lip and the vermilion border. Code 40652 involves a laceration or surgically created wound that extends through the full thickness of the lip, including the vermilion border, whose size extends up to one-half of the vertical height of the remaining lip area.