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scar contracture please?

Annette Posted Mon 05th of July, 2010 20:06:30 PM

Our doc. wants to bill the following CPT 19380, but isn't this just more of a excision of scar of the skin??

DX: Status post right breast reconstruction for right breast cancer, contracture and deformity of breast reconstruction

Operation: Excision of hypertrophic scar and release of contracture on te right reconstructed breast with complex plastic surgical closure

Procedure:

The patient had right breast cancer and underwent flap reconstruction many years ago. At this point, the patient was noted to have a hypertrophic scar on the lateral aspect of the reconstruction with contractures and deformity. The operation was carried out under MAC anesthesia. Local anesthesia was injected into the area of the surgery. The hypertrophc scar was removed by sharp dissection. All contractures were released by sharp dissection. Hemostasis was achieved with cautery where necessary. The edges of the wounds were then undermined where necessary. The wound was closed in layers using 4-0 and 5-0 Monocryl sutures as well as 5-0 Prolene stitches . Steri-Strips and Opsite were applied to the wound

some say to use 15002 but after reading coders desk reference this is done in order to receive a graft

SuperCoder Answered Tue 06th of July, 2010 02:03:36 AM

Your best option is likely the complex repair codes 13100-13102 (Repair, complex, trunk …). The text in the “wound repair” portion of CPT’s surgery section introduction specifically includes scar revision as an appropriate reason to report wound repairs. You should select an appropriate code from 13100-13102, depending on the length of the wound–whether curved, angular or stellate–in centimeters, that the dermatologist repairs.

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