Wiki Plastic Repair in ER for Eyelid Laceration

[SuzannaGG]

Help! How would you code the following. To me it seems would be debridement + Graft - or Complex Repair Only? Also thought of 67971 but I don't the inj is correct for that CPT.

Exam: A 3-cm transverse left lower eyelid laceration with herniation of periorbital fat, with devitalized tissue around the wound edges and foreign material from rock foreign body noted.
ASSESSMENT AND PLAN: The patient will undergo irrigation, debridement, repair and closure in the emergency room.
TECHNIQUE: Local infiltration given to left lower eyelid laceration, 1%
lidocaine and bicarb. Betadine prep, sterile drape. Debridement of devitalized
tissue wound edges. Removal of foreign body material and irrigation of wound. Exploration of wound showed herniation of periorbital fat. This was plicated with 5-0 Monocryl suture and subdermal closure with adjacent tissue transfer flap covers closure defect after debridement of laceration, 3 cm, to left lower eyelid complicated. After flap coverage closure was completed, 5-0Monocryl suture, subdermal closure, and interrupted 6-0 fast-absorbing gut suture closure of the skin was completed.

 

[FTessaBartels]

Cpt 13152

Based on this rather brief operative/procedure note, I would code CPT 13152.

There really isn't enough information / description given to code an adjacent tissue transfer or 67961. It is definitely NOT 67971 (which includes transfer from the OPPOSING eyelid)

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[SuzannaGG]

Thanks for the reply

Thanks for the reply, I had to code it already, but I'll save your note for future reference. This particular doctor's notes are often frustrating vague.