Wedge Excision with Reconstruction

Question:

My physician did a full thickness wedge excision with an Estlander flap of the right upper lip with reconstruction utilizing a cheek flap, adjacent tissue transfer. The defect measures 27 sq. cm. The physician used a mucosal graft from the wedge excised from the lip with reconstruction of the vermillion of the right upper lip. I am not sure what CPT code I should use?

Answer:

You should use CPT code 40525 when the physician removes a full thickness portion of the lip with local flap reconstruction. A “V” incision may be made around the lesion and through the full thickness of the lip. The lesion and surrounding tissues are removed. A local skin flap is incised and advanced to the site of the surgical wound and sutured into place with layered closure.

*This response is based on the best information available as of 12/17/20.