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excision of multiple scars on the face

  1. #1
    Question excision of multiple scars on the face
    Medical Coding Books
    I have no experience with plastic surgery. Can someone help with the coding of the following op report. Any info will help

    PREOPERATIVE DIAGNOSIS: Acquired soft tissue scar in face.

    POSTOPERATIVE DIAGNOSIS: Acquired soft tissue scar in face.

    PROCEDURE: Excision with layered closure of 15 to 18 cm of scars on her left chin, left mandibular area, and the right medial cheek.


    FINDINGS: Areas undermined gently, closed subcutaneous tissue and injected with about 10 mg of Kenalog.



    COUNTS: Correct.

    BRIEF HISTORY: The patient is a very pleasant 14-year-old who really was devastated with some scarring sustained from a dog bite incident approximately five years ago. She is now taken for revision of very wide scars that apparently are hypertrophied as well as correction of her vermilion border of her lower lip.

    DESCRIPTION OF PROCEDURE: The patient was placed supine. Anesthesia was induced without difficulty. She was then prepped and draped sterilely. The scars, which are listed above, were injected using a total of 6 mL of 1% lidocaine with epinephrine. The scars then were completely excised out and the edges undermined sharply approximately 0.5 cm in all directions and then after hemostasis had been obtained, the wounds were closed in layers with deep as well as a running subcutaneous tissue 6-0 Monocryl. The vermilion border of her left lower lip through which the scar extended had to be reapproximated since it was off approximately 2 mm. At the conclusion, her skin edges appeared to be well reapproximated. She was then injected with approximately 10 mL of Kenalog, which was mixed with lidocaine and supported with Steri-Strips. She tolerated this well. She was extubated and taken to the recovery area in stable condition.

  2. #2
    Columbia, MO
    No where in this note do I see the exact number of scars and the individual size of each one.. am I missing something?

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    PROCEDURE: Excision with layered closure of 15 to 18 cm of scars on her left chin, left mandibular area, and the right medial cheek.

    This is all the note gives.

  4. #4
    Columbia, MO
    So we have no idea as to how any and that they are from 15cm up to 18cm in diameter. Hmmmmmmmm I would send the note back for clarification or code for only one excision. Rven for the lip reapproxiamtion I do not have good documentation for that repair, it looks like one big excision which included all of the scars.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    Milwaukee WI
    Default Complex repair?
    I read this as the grand total length of all revisions was 15-18 cm

    The CPT description for complex repair reads (in part):
    ... includes the complex repair of wounds requiring more than layered closure, viz., scar revision .... extensive undermining... (emphasis added by FTB)

    I know it's titled "layered closure," but I think this is where the surgeon is headed. Although I agree the documentation is seriously lacking.

    If I'm right, then the surgeon is probably thinking 13152 +13153 (x 1? x 2? really need the EXACT total length to do this correctly.)

    If I'm wrong, (or even if I'm right) ... each scar should be separately identified by length

    Additionally if he really did a repair of lip (vermillion only) that should be separately identified in order to code 40650. (And, of course, the length of THIS repair should not be counted in the total length of repair.)

    I think the surgeon's going to have to dictate an addendum in any case.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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