Mohs repair

jdibble

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Daytona Beach, FL
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Hi all,

My plastic surgeon did a repair on a patient's brow and forehead following Mohs with irregular borders and uneven skin edges. She wants to bill 15004 & 13131. I think 15004 is incorrect because that is for prep of skin for skin replacement. What I am not sure is if she did enough work to also bill 11042 with the 13131. I don't think so, but since she is on internal audit I have to go over her errors with her so I need to have documentation to support what I tell her. Also, for a dx she is using Basal Cell carcinoma - shouldn't this be a "history of" code since the Mohs removed the cancer?

Below is part of her note - if someone could please tell me what the correct codes would be and the rational I would greatly appreciate it!

The wound was present along the superomedial portion of the brow and medial forehead. The skin edges were irregular and uneven. The skin edges were sharply debrided and the perimeter of the defect was sharply excised full-thickness through skin into subcutaneous tissue. The bipolar was used to remove some additional subcutaneous tissue to square the wound edges and reduce unnecessary bulk, and the dimensions of the wounds were 1.9-cm x 1.3-cm. Local anesthesia was placed in the circumference of the wound. Wide undermining was performed of the defect and then closure was performed with interrupted 5-0 PDS deep sutures and then a running 5-0 fast-absorbing plain gut and then Dermabond.

Thanks for the help! :)
 
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