# need help-



## codedog (Sep 27, 2011)

AM I ON THE RIGHT TRACK ON THIS 
CPT CODES 
14060
15260
21235,?, dont code much plastic surgery, would these codes be a good choice ?


PREOPERATIVE DIAGNOSES:	Squamous cell carcinoma of the right ala, sidewall, and tip of the nose.

POSTOPERATIVE DIAGNOSES:	Squamous cell carcinoma of the right ala, sidewall, and tip of the nose, status post previous excision with negative permanent sections

PROCEDURES PERFORMED:	First-stage reconstruction of the nasal tip ala and sidewall with transposition mucoperichondrial flap, cartilage graft, full-thickness skin graft, and paramedian forehead flap.

INDICATIONS:  The patient  a very large squamous cell carcinoma, which had involved the vestibular surface of the nares as well as the external surface.  He was told that the tumor should be resected and we would need to get negative margins before consideration of any reconstruction.

The tumor was resected approximately a week ago.  The permanent sections all were considered to be clear of tumor.  Again, I talked to the patient and gave him the alternatives of waiting six months prior to reconstruction, which may be safer even with the negative margins, but the patient wished to proceed with reconstruction as he did not want to be deformed for period of six months.

OPERATIVE PROCEDURE:  He was taken to the operating room and placed under adequate general endotracheal anesthesia.  The face was prepped with Betadine and draped in a solution and draped in a customary fashion.

Attention was first turned to excising the epithelium that had grown over the wound surfaces and this was done.  An additional 2 mm of tissue was resected in order to freshen the edges.

The first thing that was done was to provide a vascular lining for the sidewall of the nose and this was done by making an incision across the dorsal septum leaving behind approximately a centimeter of dorsal strut.  This incision was done on the ipsilateral side of the nose and using a Cottle speculum, the cartilage was elevated away from this side of the nose.

Next, a Killian incision was made on the contralateral side and the contralateral mucosa was elevated off of the perichondrium.

A block of septal cartilage was then harvested with the use of swivel knife and scalpel blades and once this had been harvested, a proximal cranial incision was made in the contralateral perichondrium down to the floor of the nose.
Finally, the perichondrium was incised along the floor of the nose and the flap was passed through the defect and the ipsilateral perichondrium and sewn into placed to line the new sidewall of the nose.  This was done without difficulty.

The cartilage was then shaved to form a sidewall strut and was sewn into place with few transfixion sutures across the mucoperichondrium.

A template was then made of the opposite side of the nose.  The eventual hope was to do a heminasal reconstruction.

This patient has very glabrous skin and the scars on the tip of his nose were not proved to be favorable.

This template was then inverted and placed on the opposite side of the nose and marks were made where the feet of the ala needed to be.

This left behind approximately 7-10 mm cheek skin, which had been resected.

A cheek advancement flap was then incised along the nasolabial fold and advanced into position.

The dog-ear was removed superiorly and the cheek portion of the reconstruction was completed.

A full-thickness skin graft was then harvested from the right postauricular area and this was sewn to the mucoperichondrium, which had been transposed into the defect to form a new lining of vestibular skin.  Finally, the template was rotated up onto the forehead and a forehead flap was designed using the template, which had been created.  The base of the flap was placed over a fairly loud Doppler pulse, which was located in the area of the trochlea.

The flap was then elevated including the frontalis muscle down to just above the orbital rim.  At this point, a subperiosteal dissection proceeded and the flap could be easily rotated down into position.

Hemostasis was achieved with electrocautery.  The flap bled profusely during its transfer.  The forehead was partially closed along the stalk of the flap and partially left open.

The template was then returned to the nose and measurements were made to try to find the exact spot of the base of the ala needed to be symmetrical.  This was de-epithelialized and the ala was placed down there.  The rest of the flap was then sewn in with multiple 5-0 Vicryl sutures.  Because this patient is a smoker, no thinning of the flap was possible.

Additionally, even though a heminasal reconstruction was eventually planned, we did not excise the half of the remaining lobule until we were certain that this flap was going to be viable.  The extra portions of the flap were then covered with Biobrane.  The skin graft was then sewn to the edge of the flap along the vestibular margin and several transfixion sutures were placed.

The Biobrane was also placed in the forehead defect.

The nose was then lightly packed with Surgicel.


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## ChRivera (Sep 28, 2011)

After reading through the report you posted, I have to admit that it did take me a little while to figure it out but the CPT index listing for “Graft” helped simplify what sections of the CPT should be used.

This is how I would code the op report (before the addition of modifiers and sequencing):
15004
20912
14040
15260
15731

…and here's the method to my madness:

PROCEDURES PERFORMED:	

First-stage reconstruction of the nasal tip ala and sidewall with transposition mucoperichondrial flap
cartilage graft
full-thickness skin graft
paramedian forehead flap.


Op Report: “Attention was first turned to* excising the epithelium that had grown over the wound surfaces *and this was done. *An additional 2 mm of tissue was resected in order to freshen the edges*.”

Coding: Although not explicitly listed on the procedures performed, this counts as surgical preparation of a wound for skin graft, so I code 15004 - “Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children”


Op Report:  “*A block of septal cartilage was then harvested* with the use of swivel knife and scalpel blades and once this had been harvested, a proximal cranial incision was made in the contralateral perichondrium down to the floor of the nose. Finally, the perichondrium was incised along the floor of the nose and *the flap was passed through the defect and the ipsilateral perichondrium and sewn into placed to line the new sidewall of the nose. This was done without difficulty.*

The cartilage was then shaved to form a sidewall strut and was sewn into place with few transfixion sutures across the mucoperichondrium.”

Coding:  cartilage graft. Use the CPT index for Graft -> Cartilage -> Harvesting -> see codes 20910-20912. So I used code 20912 - “Cartilage graft; nasal septum”


Op Report: “This patient has very glabrous skin and the scars on the tip of his nose were not proved to be favorable.

This template was then inverted and placed on the opposite side of the nose and marks were made where the feet of the ala needed to be.

This left behind approximately _7-10 mm cheek skin_, which had been resected.

*A cheek advancement flap was then incised along the nasolabial fold and advanced into position.*

The dog-ear was removed superiorly and the cheek portion of the reconstruction was completed.”

Coding: Cheek advancement flap -  Code 14040 - “Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less”


Op Report: “*A full-thickness skin graft was then harvested from the right postauricular area *and this was sewn to the mucoperichondrium, which had been transposed into the defect to form a new lining of vestibular skin.”

Coding: Full-thickness skin graft. I also arrived at code 15260 - “Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less”


Op Report: “Finally, the template was rotated up onto the forehead and *a forehead flap was designed* using the template, which had been created. The base of the flap was placed over a fairly loud Doppler pulse, which was located in the area of the trochlea.

*The flap was then elevated including the frontalis muscle down to just above the orbital rim. At this point, a subperiosteal dissection proceeded and the flap could be easily rotated down into position.*

Hemostasis was achieved with electrocautery. The flap bled profusely during its transfer. The forehead was partially closed along the stalk of the flap and partially left open.”

Coding: Paramedian forehead flap. Code 15731 - “Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap).”

I know my answer is lengthy but following this process usually helps me code better when I'm unfamiliar with a specialty. I hope this helps and I'm interested to hear if anyone else arrived at different codes or even fewer more specific codes. Cheers!


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