AAE does not provide coding/reviewing for operative reports and chart notes. SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail firstname.lastname@example.org for more information.
In addition to it, on the basis of review of provided codes, here are the suggestions:
ICD-10 codes are correctly used for the provided descriptors.
CPT 14301 is correct for Adjacent Tissue Transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm and CPT 14001 is correct for Adjacent Tissue Transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm.
On the other hand, CPT code ranges 12001-12007, 12031-12037 and 13101-13102 are for simple, intermediate and complex wound repair, respectively. Since, you performed excision of her previous mastectomy scar and surrounding redundant skin and subcutaneous tissues, then these series codes would not be appropriate to bill.
However, CPT code 19301 is for partial mastectomy. But, when you are performing excision of redundant skin and subcutaneous tissue along with mastectomy with the same site and same incision, then it is not appropriate to bill for the skin excision separately. In this scenario, you can append modifier 22 (Increase Procedural Services) with the mastectomy procedure.
Append modifier 22 to a surgical procedure when the physician’s work required to perform the procedure is more than is typically needed.
In order to append modifier 22 to a surgical procedure, check that the physician documented the reason(s) why the work he performed was more than he typically performs, and the documentation should include any or all of the following:
- Increased intensity
- Additional time
- Technical difficulty
- Severe patient condition, which causes the surgery to be difficult, dangerous to the patient, and requires additional physical and mental effort from the physician
An unusual procedure is not when the physician took only a few extra minutes on the patient’s case or when the physician documents that the procedure was only slightly more difficult. There is an average range of difficulty for every procedure. A procedure could be slightly more difficult and still meet the definition of the procedure and not warrant appending modifier 22.
Although, if the excision of skin and subcutaneous tissue is performed separately, then code series 15830-15839 is applicable for the excision of excessive skin and subcutaneous tissue. Out of which, CPT 15839 is the code for trunk/torso site.
Hope this helps!