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How would you code this case?

  1. #1
    Jacksonville Beach, FL
    Default How would you code this case?
    Medical Coding Books
    I used the advancement code, but the pts mother is questioning how I billed the case, how would you code this case? Thank you for any input.


    PREOPERATIVE DIAGNOSIS: Complex chin scar, status post laceration repair.

    POSTOPERATIVE DIAGNOSIS: Complex chin scar, status post laceration repair.

    PROCEDURE: Wide local excision with local advancement flaps with geometric broken line closure of chin scar.

    ANESTHESIA: Local anesthetic using 1% lidocaine with 1:100,000 epinephrine.

    DRAINS: None.

    SPECIMENS: None.

    PACKS: None.

    DISPOSITION: Stable. Transferred to PACU.

    HISTORY OF PRESENT ILLNESS: This is a 4-year-old white female who is status post dog bite laceration to the chin with resultant repair and resultant scar. The patient waited 16 months and has come to my office for evaluation. Upon evaluation of the scar, repair was deemed necessary. After the potential risks, benefits, and complications of the procedure were explained to the patient and the parents including scarring, lip asymmetry, nerve damage, hematoma, infection, the child was made ready for surgery.

    OPERATIVE SUMMARY: The child was brought into the room, properly identified and laid in the supine position, general LMA anesthesia was induced. The tube was taped to the midline and the bed was turned 90 degrees counterclockwise to the surgeon's control. The scar was properly addressed. Geometric broken line pattern was marked and a 1% lidocaine with 1:100,000 epinephrine was infiltrated. The scar was removed in toto. The local advancement flaps were created and the deep closure was achieved with a 5-0 PDS type suture. The subcuticular stitches were placed with 5-0 Monocryl type sutures and this was complemented with a 6-0 fast-absorbing gut in a vertical mattress fashion. Benzoin and tapes were applied.

  2. Default
    CCI bundling show complex repair or excision of lesion bundling into 14040

  3. #3
    Milwaukee WI
    Default Size missing
    Size of flap is missing, but I would still code 14040 (as it is for 10 sq cm or less),

    F Tessa Bartels, CPC, CEMC

  4. #4
    I agree with Ftessa.

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