# Component separation/Hernia coding



## abuscay (Feb 1, 2018)

Hi All, 

I'm looking for coding input regarding the operative note below. My thoughts are 15734/50, 49565, 49568. 

PROCEDURE PERFORMED:
1.   Component separation, retrorectal, 25 x 16 Marlex mesh repair of complex ventral incisional hernia.
2.   Debridement of devitalized tissue and removal of mesh. 
3.   Flap advancement, right and left, bilateral, with component separation.  The surface area was 30 x 25 bilaterally.

FINDINGS AND PROCEDURE:
With the patient under satisfactory endotracheal general anesthesia, the anterior abdomen was draped and prepped in the usual fashion.  Patient identification and the proposed procedure were confirmed by the operative team.  The patient received the usual prophylactic antibiotic and anticoagulation regimens.  A longitudinal incision between xiphoid process to the pubis was performed.  This hernia extended from the pubis up to above the umbilicus, where the recurrent hernia was present and with a significant amount of diastasis recti was present to the xiphoid.  The midline incision was mobilized down to the subcutaneous fascia.  The external layer of the rectus was exposed for approximately 15 cm on each side to the lateral margins of both rectus muscles superiorly and inferiorly to the space of Retzius.  The devitalized hernia sac, including mesh, was removed and excised.  No significant adhesions noted anteriorly.  The opening in the peritoneum was closed with running sutures of 2-0 Vicryl and the posterior rectus fascia with the peritoneum closed with running sutures of #1 PDS.  Anterior to this, a large Marlex mesh repair in the retrorectal position that measured 26 x 16 cm was placed in position and anchored circumferentially at 2 cm intervals with transfascial sutures of #1 Nurolon.  This was done in interrupted fashion.  The anterior rectus fascia was approximated without significant difficulty with interrupted near and far sutures of #0 Nurolon.  Nurolon was used to anchor the mesh.  Two 19 Blake drains were left in the subcutaneous space and exteriorized through separate incisions and secured to the skin with 3-0 nylon sutures.  The subcutaneous tissue was closed with running sutures of #2-0 Vicryl and the skin with staples.  Dressings were applied.  The patient was awakened and transferred to the recovery room in stable condition.


Any and all input is appreciated!


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## jennruss (Feb 2, 2018)

*Component sep*

15734  is used for muscle flap.  I was recently hired for an in house coder at General Surgery.  But the coding dept is not coding these correctly....and they remove my codes prior to billing. so if that is incorrect please let me know the proper billing. My surgeon is frustrated because his bih with component sep. took 5 hours..and he has argued with them over this for a long time...they still are not billing the 15734. I have read if that is done bilaterally..to bill twice with a mod 59


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## LABARBERA (Mar 29, 2018)

*Roberta CPC-COC-CPMA*

I have been coding general surgery for almost 14 years. 15734 is the correct code for the component release. They usually do this bilaterally, often as many as 4 releases. However, it can only be billed 2 times. It will not take modifier 50, LT, or RT. It has to be billed on 2 lines with modifier 59 on the second line. I am also a coding educator for the healthcare system I work for. I am responsible for educating the providers as well as the coders.
 You would bill the hernia repair, mesh placement, mesh removal, and the component releases. The component release has the highest RVU assignment.

Hope this helps.


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## abuscay (Mar 30, 2018)

Thank you so much! That is very helpful.


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## karansinghchauhan (Apr 3, 2018)

That's fine.


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## mnunez (Apr 3, 2018)

*Laparoscopic bilateral component separation*

How would you bill for these same scenario but done Robotic laparoscopic? I mean what CPT code would bill since 15734 is for an open procedure?


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## KimberlySherman (Dec 18, 2022)

The component separation technique for abdominal closure is not a true flap as described by 15734 "Muscle, myocutaneous, or fasciocutaneous flap; trunk." In 15734, tissue is harvested at a site distant from the defect, a pedicle is preserved to maintain vascularization of the flap, and the flap is then moved to the defect site and inset. The donor site is then repaired. Any skin grafts required are coded separately. By contrast, in component separation, tissues adjacent to the defect are incised, undermined, and mobilized to close the defect. This procedure is termed an advancement flap, and for the trunk, it is coded with the ATTR (Adjacent Tissue Transfer and Rearrangement) CPTs 14000, 14001, 14301, and 14302, depending on the size of the defect and donor area. The mobilization of adjacent advancement flaps of "component" layers of tissue (undermining and advancement of more than one layer of muscle, fascia, or other tissues) is covered by the ATTR CPTs.

In ATTR, coding is based on the area in square centimeters of the primary (the defect being closed) and secondary (due to flap design) defects. Z-plasty, W-plasty, VY-plasty, rotation flap, advancement flap, double pedicle flap, and random island flap are all ATTRs per CPT. Reimbursement for ATTR is determined by the size of the primary and secondary defects added together, and frequently pays more than 15734, 15734.59 due to the large size of the repairs.

I have included authoritative guidance on 15734 versus advancement flaps below.

 "The physician repairs a defect area using a muscle, muscle and skin, or a fasciocutaneous flap. The physician rotates the prepared flap from the donor area to the site needing repair, suturing the flap in place. The donor area is closed primarily with sutures. If a skin graft or flap is used to repair the donor site, it is considered an additional procedure and is reported separately. Report 15733 for a muscle, myocutaneous, or fasciocutaneous flap obtained from the head and neck with named vasculr pedicle such as temporalis or sternocleidomastoid; 15734 if obtained from the trunk; 15736 if obtained from an upper extremity; and 15738 if obtained from a lower extremity." Optum Encoder Pro.com Professional

15734: Excludes Contiguous tissue transfer flaps (14040-14041, 14060-14061, 14301-14302) - CPT 2022

"15734 A 55-year-old female with a history of breast cancer treated with mastectomy followed by radiation therapy presents with a large non-healing radiation ulcer of the left lateral chest. The excision of the radiation ulcer results in the exposure of sev-eral ribs. The defect is reconstructed with a pedicled latissimus muscle flap. The entire latissimus muscle is harvested through a separate incision and then tunneled through the axilla to reach the defect. The muscle is secured to the chest wall with interrupted sutures and the donor site is closed primarily. The muscle is covered with a split thickness skin graft. The excision and the skin graft are coded separately...  After the ablative part of the procedure has been completed, obtain appropriate measurements of the defect and plan for the size of the flap. Make an incision over the ipsilateral latissimus muscle. Dissect to the fascia, which is elevated off the muscle. Expose the anterior and posterior borders of the muscle and continue the dissection inferiorly until enough length is obtained to reach the defect. Divide the inferior portion of the muscle. Elevate the muscle off the chest wall and isolate it on the thoracodorsal vascular pedicle. Create a tunnel subcutaneously to reach the defect and enlarge it to accommodate the muscle flap. Transpose the flap and reassess the vascular pedicle. Inset the flap into the chest wall defect and suture in place after placing a closed suction drain. Close the donor site primarily over the suction drains. Harvest a split-thickness skin graft from the ipsilateral thigh and mesh and secure it to the muscle. Apply a bolster dressing over the skin graft. Cover the skin graft donor site with an occlusive dressing." CPT Vignettes (AMA)

The excerpts below are from the invaluable _CPT Assistant_ article "Island Pedicle Flaps" (Dec 2012). Please also refer to the official CPT ATTR guidelines (CPT book).

_"Advancement Flap_. This type of flap involves incising, undermining, and moving forward a flap of tissue to cover the defect, then suturing the flap into place."

"Clinical Example (14040) [ATTR of face] A 63-year-old male with an excised basal cell carcinoma on the left medial cheek leaves a defect through the subcutaneous plane that is 1.4 cm in diameter and involves the lower part of the left lower eyelid. To prevent ectropion, reconstruction via adjacent tissue transfer is performed.
Description of Procedure (14040) Skin markings are made to outline the excision of the lesion and the appropriate margin. Local anesthetic is injected. After an adequate hemostatic wait, the lesion is excised. The lesion is oriented and marked with sutures. Hemostasis is obtained. Care is taken to determine the availability of adjacent tissue for closure and the possibility of functional impairment or anatomic distortion of adjacent structures. An adjacent flap is designed. The flap is incised and raised at the appropriate level. The flap is rotated into the defect. Tension is assessed and additional dissection is performed as necessary. Drains may be placed. The flap is sutured into position. A sterile dressing is applied.
...
Terminology Review
...
_Advancement Flap_. This type of flap involves incising, undermining, and moving forward a flap of tissue to cover the defect, then suturing the flap into place."


"Clinical Example (15734) A 55-year-old female with a history of breast cancer treated with mastectomy followed by radiation therapy presents with a large nonhealing radiation ulcer of the left lateral chest. The excision of the radiation ulcer results in the exposure of several ribs. The defect is reconstructed with a pedicled latissimus muscle flap. The entire latissimus muscle is harvested through a separate incision, and is then tunneled through the axilla to reach the defect. The muscle is secured to the chest wall with interrupted sutures and the donor site is closed primarily. The muscle is covered with a split thickness skin graft. The excision and the skin graft are coded separately.
Description of Procedure (15734) After the ablative part of the procedure has been completed, appropriate measurements of the defect are obtained and planning for the size of the flap is performed. An incision is made over the ipsilateral latissimus muscle. Dissection is carried down to the fascia, which is elevated off the muscle. The anterior and posterior borders of the muscle are exposed, and the dissection continues inferiorly until enough length is obtained to reach the defect. The inferior portion of the muscle is then divided and the muscle elevated off the chest wall and isolated on the thoracodorsal vascular pedicle. A tunnel is created subcutaneously to reach the defect and enlarged to accommodate the muscle flap. The flap is transposed and the vascular pedicle re-assessed. The flap is inset into the chest-wall defect and sutured in place after placement of a closed suction drain. The donor site is closed primarily over suction drains. A split-thickness skin graft is harvested from the ipsilateral thigh, meshed and secured to the muscle. A bolster dressing is applied over the skin graft. The skin graft donor site is covered with an occlusive dressing."


Frequently Asked Questions
Question: Patient presents with cutaneous necrosis of right reconstructed breast. An excision of the right breast cutaneous necrosis 3x10 cm is performed. Fasciocutaneous advancement flap reconstruction is performed with 2 flaps. Would code 15734, Muscle, myocutaneous, or fasciocutaneous flap; trunk, be appropriate to report, and would it include the excisional debridement, or should that be reported separately with code 15002?
Answer: Even though the fascia and overlying tissues were advanced, procedurally, the description is undermining (ie, complex repair). Therefore, codes 13101, Repair, complex, trunk; 2.6 cm to 7.5 cm, and 13102, Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure), may be reported in addition to code 15002. As stated in the adjacent tissue transfer or rearrangement guidelines, undermining of only the adjacent tissues to achieve closure, without additional incisions, does not constitute adjacent tissue transfer, and therefore, the complex repair codes 13100-13160 should be reported instead.
...
Question: Please explain an advancement flap and how it is reported.
Answer: An advancement flap involves making an incision and elevating a flap to move it over to cover a defect. An advancement flap is reported with codes 14000-14350. Undermining tissues does not constitute an advancement flap. Undermining is reported with the complex repair code series (13100-13160)."


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## KimberlySherman (Dec 18, 2022)

abuscay said:


> Hi All,
> 
> I'm looking for coding input regarding the operative note below. My thoughts are 15734/50, 49565, 49568.
> 
> ...


The closure described is a 30 cm complex repair of the abdominal wall. If performed alone, it may be coded. In this case, complex repair is included in the hernia repair with mesh. Per _CPT Assistant_ (Dec 2012) - "*Question*: Patient presents with cutaneous necrosis of right reconstructed breast. An excision of the right breast cutaneous necrosis 3x10 cm is performed. Fasciocutaneous advancement flap reconstruction is performed with 2 flaps. Would code 15734, Muscle, myocutaneous, or fasciocutaneous flap; trunk, be appropriate to report, and would it include the excisional debridement, or should that be reported separately with code 15002? *Answer*: Even though the fascia and overlying tissues were advanced, procedurally, the description is undermining (ie, complex repair). Therefore, codes 13101, Repair, complex, trunk; 2.6 cm to 7.5 cm, and 13102, Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure), may be reported in addition to code 15002. As stated in the adjacent tissue transfer or rearrangement guidelines, undermining of only the adjacent tissues to achieve closure, without additional incisions, does not constitute adjacent tissue transfer, and therefore, the complex repair codes 13100-13160 should be reported instead."


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## KimberlySherman (Dec 18, 2022)

mnunez said:


> *Laparoscopic bilateral component separation*
> 
> How would you bill for these same scenario but done Robotic laparoscopic? I mean what CPT code would bill since 15734 is for an open procedure?


Only the laparoscopic hernia repair may be coded. The closure documented is a complex repair and is included in the hernia repair code.


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