Surgical Coding: Scar Revision on Previous Mastectomy Site

Posted on 15. Dec, 2009 by Editor in Coding Challenge

Tip: Find mastectomy scar revision in wound repair

Question: Our surgeon performed a scar revision on the site of a previous mastectomy. The procedure involved excising a 16.5 cm curved scar before performing a layered closure. How should we code this?

Answer: You should use complex wound repair codes for the scar revision procedure that you describe. Specifically, you should use the trunk codes 13101 (Repair,complex, trunk; 2.6 cm to 7.5 cm) and +13102 (… each additional 5 cm or less [List separately in addition to code for primary procedure]).

Measure repair: Whether straight, curved, angular, or stellate, the operative report should note the length of the repair. Because your report stated 16.5 cm, you should report 13101 for the first 7.5cm and +13102 x 2 for the additional 9 cm.

You should not code separately for the scar excision. When the surgeon removes the scar, he creates the “defect” that he then repairs. The scar excision plus the layered closure justifies selecting the complex wound repair codes rather than intermediate wound repair.

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Tags: +13102, 13101, mastectomy, scar revision, surgeon, surgery, surgical, wound repair