Lip biopsies and repairs

Cracking the Code

Alexander Miller

Dr. Miller, who is in private practice in Yorba Linda, Calif., represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.

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You biopsy a suspected basal cell carcinoma on the lip using punch technique. You document the procedure in the patient record, transmit the service and diagnostic information to your biller, and off goes the bill to the patient’s insurer. Did your office bill correctly, or did your office (which means you) unwittingly commit fraud?

The answer to the above question is determined by precise knowledge of the CPT descriptors and by how CPT code assignments are generated in your office. The CPT offers several site-specific biopsy codes that may be appropriately used when exact qualifying criteria are met. In the case of the lip, the CPT contains code 40490, “Biopsy of lip.” One may think, “Great, I’ve found a specific code for the lip. I’ll use it.” However, there is a restriction: the lip biopsy code is located in the “Digestive” section of the CPT, and the descriptor of the code is preceded by the following qualifier: “(For procedures on skin of lips, see 10040 et seq).”

Consequently, when billing for a lip biopsy, the first step is to determine whether the biopsy was done on the lip skin or on the lip vermilion. For lip vermilion biopsies, 40490 is appropriate. Skin of the lip biopsies should be coded with the integumentary section biopsy code, 11100. If the biopsy is done on the mucosal tissue, the biopsy should be coded with 40808. [pagebreak]

The second step is to ensure that the proper code is assigned and billed. You may know that you just did a biopsy of lip skin, but is that message precisely transmitted through your billing process? Your billing routine may have you circling a code on a billing sheet or choosing a code directly in your EHR system. In that case, you determine the code. If a coder or billing service chooses the code, then they must be trained to recognize the location specificity of the lip biopsy code and to code accordingly. Your electronic health records module may be integrated with your practice management software and may automatically select CPT codes for your services based upon your E/M and procedural data input. Such a system should allow and/or prompt you to select the optimal code when more than one may be appropriate.

Lip procedure billing challenges are not limited to biopsies. There are multiple lip-specific CPT codes dealing with excisional surgery and reconstruction. These include codes describing vermilionectomy, transverse (vermilion) and vertical excisions, broad resections with reconstruction such as Estlander and Abbe-Estlander flaps, lip repairs, and procedures done on the internal, mucosal aspect of the lip, including incisions, biopsies and excisions. See sidebar for a complete listing of codes.

For the purpose of measuring height when billing for a lip repair, the limits of the upper and lower lip are specified as follows: the upper lip is bordered inferiorly by the inferior edge of the vermilion and superiorly by the nasal alar rim and sill as well as the cheek fold. The inferior extent of the lower lip is limited by the mental crease, inferior to which is the chin. [pagebreak]

Example 1: Suspecting a squamous cell carcinoma of the vermilion border of the lip, you do a biopsy encompassing the vermilion border and adjoining skin and lip vermilion using shave technique. You submit 11100 as your biopsy bill.

Answer: Correct. CPT defines 11100 as: “Biopsy of skin, subcutaneous tissue, and/or mucous membrane (including simple closure), unless otherwise listed; single lesion.” You biopsied both the skin and overlapped onto the vermilion, so your code choice is appropriate. However, you may also be justified in billing 40490 instead, as your biopsy crossed the vermilion margin into the vermilion. This is a rare case in which either code is fitting.

Example 2: You punch biopsy a localized nodularity on the internal, mucosal aspect of the lower lip and code 40490 for the procedure.

Answer: Incorrect. A biopsy of the internal, mucosal aspect of the lip is specified by its own, dedicated CPT code, 40808, “Biopsy, vestibule of mouth.” The CPT defines the vestibule of mouth as: “the part of the oral cavity outside the dentoalveolar structures; it includes the mucosal and submucosal tissue of lips and cheeks.” 

Example 3: You repair a deep and broad upper lip vermilion, skin, and muscle Mohs surgical defect with a full thickness vertical wedge excision measuring two thirds of the lip height. Having done a lip wedge, you code the repair as CPT 40520, “V-excision with primary direct linear closure.”

Answer: Incorrect. Although a lip wedge excision was done as a component of the repair, optimal coding is for the repair, and not for the excision that is a component of the repair. This convention is similar to that used for cutaneous linear repairs done after Mohs surgery, in that rather than coding for an additional excision in producing a repair, one codes based upon the complexity of the repair itself. Specific lip repair codes (cheiloplasty) are 40650 40654, and are appropriate to use for surgically created wounds (CPT Assistant, July 2000):

40650 Repair lip, full thickness, vermilion only

40652 up to half vertical height

40654 over one-half vertical height, or complex

For the above vignette, since the vertical height of the repair is over one-half of the lip height, the appropriate CPT code is 40654. [pagebreak]

Other lip biopsy and repair codes

Excision

40490 Biopsy of lip

40500 Vermilionectomy (lip shave), with mucosal advancement

40510 Excision of lip; transverse wedge excision with primary closure

40520 V-excision with primary direct linear closure (For excision of mucous lesions, see 40810-40816)

40525 full thickness, reconstruction with local flap (e.g., Estlander or fan)

40527 full thickness, reconstruction with cross lip flap (Abbe-Estlander)

40530 Resection of lip, more than one-fourth, without reconstruction (For reconstruction, see 13131 et seq)

Repair (Cheiloplasty)

40650 Repair lip, full thickness; vermilion only

40652 up to half vertical height

40654 over one-half vertical height, or complex

40700 Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral

40701 primary bilateral, 1-stage procedure

40702 primary bilateral, 1 of 2 stages

40720 secondary, by recreation of defect and reclosure (for bilateral procedure, report 40720 with modifier 50)

(To report rhinoplasty only for nasal deformity secondary to congenital cleft lip, see 30460, 30462)

(For repair of cleft lip, with cross lip pedicle flap [Abbe- Estlander type], use 40527)

40761 with cross lip pedicle flap (Abbe-Estlander type), including sectioning and inserting of pedicle 

 

Related Resources

Other lip biopsy and repair codes