Question Excision of lip mucocele

AN2114

Guru
Messages
112
Location
Auburn Hills, MI
Best answers
0
The doctor excised a lower lip mucocele that went deep through the subcutaneous tissue into the fat and muscle but did a multi layer closure and not a complex closure. Can I still use cpt code 40816 since it went into the muscle even though it is just multilayer closure? Below is the op report.

Once proper hemostasis was achieved, using curved pair of iris scissors as well as hemostat and electrocautery, we were able to dissect the mucocele out of the lower lip mucosa. We did dissect it deep to the mucosa as well as into the associated subcutaneous fat and down into the musculature. We were able to remove this in its entirety after manipulation with curved iris scissors, Bovie and Jakes forceps. Once this was removed using a 4-0 chromic x5, we did close the incision site.
 

jackjones62

Expert
Messages
279
Location
Niantic, CT
Best answers
1
Hello, the answer is YES, if the actual excision is complex. CPT 40816 does not require a complex closure, it is indicating that the removal is "complex". As your surgeon indicated they did a deep dissection thru the mucosa and associated subcu fat and down to the musculature via curved iris scissors, Bovie and Jakes forceps, I'd say this was not a simple removal.

Jennifer
Coding Analyst
 
Top