Wiki lip ptosis excision

[BFAITHFUL]

patient had an excision of left upper lip 3.0cm & complex repair of 3.5cm defect, how would this be coded , would it be an excision lesion code with or just 13xxx for complex repair?

clinical history: status post MVA, there was excessive scar tissue that exists in left portion of lip completely resected. she has ptosis of the upper lip which causes her ability to properly speak and asymmetry to her smile due to the ptosis. the patient had orbicularis muscle repair at this point.

procedure:
using digital pressure on the labial artery laterally & medially, the patient then had a complete excision of the excessive mucosa on the wet and dry area of the left upper lateral lip. when this was done then the ptotic left upper lip orbicularis oculi muscle was identified. this was secured to the upper orbicularis oculi muscle as well as the levator superioris in the zygomaticus major minor and major muscles with 4-0 vicryl. the patient had the appropriate show of the upper lip and overhaning ptosis of the lip completely correct. extensive undermining after the repair of the muscle was then done of the mucosa.

 

[FTessaBartels]

40654

Did you look at 40654 - Repair, lip, fll thickness; over one-half vertical height, or complex ...

The lay description reads: The physician repairs a laceration extending through the full thickness of the lip. In 40652, a laceration or surgically created wound of up to one-half the vertical height of the lip is closed with layered sutures and in 40654, a wound of more than one-half the vertical height of the lip is repaired (emphasis added by FTB)

F Tessa Bartels, CPC, CEMC

 

[BFAITHFUL]

thank you