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Help needed-scar revision coding question

  1. Default Help needed-scar revision coding question
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    I'm new to plastics coding and I need help with the below scenario.

    The procedure - Scar Revision & Excision of the Hypertrophic Scar of the Right Forearm.

    Op report reads as follows-" Attention turned to right forearm where a hypertrophic scar was noted with 4 to 5 raised .5cm round keloid type hypertrophic scars in a linear configuration for about 4 cm in length along proximal volar right forearm. Excision of the hypertrophic scars in a linear fashion was then outlined, & as it was approaching the cubital fossa, the scar was angled slightly more transversely to prevent the vertical scar from going across the cubital fossa. The inferior portion was angled slightly in opposite direction to create an S type of scar to minimize scar contracture. The intervening scar tissue was excised and sent for pathological exam. Wound margins were now undermined, advanced and closed with #5 Monocryl interrupted intradermal suture & #5-0 prolene continous intradermal suture.

    Would I use px 13121 & 11400 x 5 for the excision of keliod scar or would I just use px 13121 by itself??


  2. #2
    Milwaukee WI
    Default 13121
    I would use the complex repair code, alone. The definition of complex repair includes scar revision, which is what is described in your op note.

    By the way, you would never code 5 excisions if only ONE incision was made.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    I just ran across a similar issue, wound exploration resulted in a scar tissue excision. I was curious as to why a benign integ excision code e.g. 11403 would not be billed with the complex repair when CPT specifically states that a complex repair does not include 11400-11446? In the definition of a scar repair it lists scar revision as an example of wound requiring a more than layered repair not that it is included. "viz., scar revision"

  4. #4
    Columbia, MO
    There is an old CPT assistant that states to code a scar removal as a benign excision. I am not convinced the op note supports a complex repair. He states the incision ran for 4 cm so I would use the 11404 code and an intermediate repair 12032, if I were convinced of the complex repair then it would be 13121 plus the 11404.

    Debra A. Mitchell, MSPH, CPC-H

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