# 2 Flaps, Same Site, Can U Bill For Both



## ljk7172

Hi,

If 2 Flaps Were Used 14060, One Being A Rotation Flap And The Other A Transposition Flap, Would You Code Each Separately Or Would You Add Them Together?  (this Is For The Same Moh's Site).  I Know With Other Closures Within The Same Anantomical Site That You Add Them Together But I Am Not Seeing Where It Specifies In The Cpt Book When It Comes To Flaps (adjacent Tissue Transfers).

Any Help Would Be Appreciated.


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## magnolia1

Hope this helps: (This is from a July 2008 CPT Assistant)

Adjacent Tissue Transfer or Rearrangement 

Adjacent tissue transfer or rearrangement procedures (local flaps) are described by CPT codes 14000-14350 and represent local flaps, including rotation, transposition, and advancement. To perform adjacent tissue transfers, a tissue flap is created by surgically freeing the skin and underlying subcutaneous tissue and/or fascia. The base of the tissue flap remains connected to one or more borders of the donor site, thus maintaining the blood supply to the surgically created flap.

The following table describes types of local or adjacent flaps.



As with many of the codes in the Integumentary System section, codes 14000-14300 are reported on the basis of the anatomic area and defect size. The term defect includes the primary and secondary defects. The primary defect, which results from the excision, and the secondary defect, which results from flap design to perform the reconstruction, are measured together to determine the square centimeter area (in sq cm) in order to choose the correct code.

The excision of a benign lesion (codes 11400-11446) or a malignant lesion (codes 11600-11646) is not reported separately with codes 14000-14300. When an adjacent tissue transfer or rearrangement is performed after the excision of lesions, the excision of the lesion is included with codes 14000-14350 and is not reported separately.

When it is applied to the repair of lacerations, an adjacent tissue transfer or rearrangement must be purposely performed by the surgeon to accomplish the repair. For example, if direct closure or rearrangement of traumatic wounds results in the incidental configuration of a "Z", it is not appropriate to report these codes.

The following table is provided to assist in selection of the appropriate code.


Example 1

A physician excises a 1.5 cm lesion on the cheek with an excised diameter of 1.8 cm (primary defect, approximately 3.2 sq cm) and performs an adjacent tissue transfer (flap dimension of 1.4 3 3.0 cm) which equals a 4.2 sq cm secondary defect). In this instance, only code 14040, Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less, would be reported, because the excision of the lesion is included in the adjacent tissue transfer codes. The primary defect (3.2 sq cm) plus the secondary defect (4.2 sq cm) equals 7.4 sq cm for dimensions of the total defect.

Sometimes a tissue transfer or rearrangement procedure creates an additional defect that must be repaired. If a skin graft or another flap is necessary to close a secondary defect, this should be reported separately, as indicated in Example 2.

Example 2

A 6 cm malignant lesion with 0.5 cm margins and a 7 cm excised diameter is excised from the neck. A transposition flap is used to close the 50 sq cm defect. The flap donor site is partially closed, but there is a remaining 10 sq cm defect, which requires a split-thickness skin graft:

14300   Adjacent tissue transfer

15120 51   Split-thickness autograft

The lesion excision is included in the adjacent tissue transfer code and is not coded separately. The skin graft necessary to close the flap donor site is coded in addition to the flap.

Note that modifier 51, Multiple Procedures, is appended to CPT code 15120 to indicate that multiple procedures were performed at the same session by the same physician. However, reporting practices related to these services may vary, and third-party payers should be consulted for their preferred method of reporting multiple procedures. Some payers may require the use of modifier 59.

Example 3

A patient's nostril is retracted secondary to a scar. The scar is excised, and an 11 sq cm dorsal nasal flap used to repair the 2 sq cm defect resulting from the scar excision.

14061   Adjacent tissue transfer

When a scar is excised and the defect repaired with a flap, report only the appropriate adjacent tissue transfer code, which includes the scar excision.

Example 4

A lesion is removed from the forehead, resulting in a 5.2 sq cm defect, and another lesion is removed from the neck, resulting in a 7.3 sq cm defect; both lesions require rotational and advancement flaps of 10.2 sq cm and 12.2 sq cm, respectively, to provide closure.

14041   Adjacent tissue transfer, forehead lesion

14041 51   Adjacent tissue transfer, neck lesion

If two lesions from the same anatomical classification are removed, with both of the resulting defects requiring adjacent tissue transfer closure, the appropriate code from the 14000-14300 series may be reported for each tissue transfer (eg, flap advancement) performed, provided *the defects have distinct margins and are not contiguous*. For the forehead and neck excisions in this example, CPT code 14041 is reported twice, with modifier 51 appended to the second code. Although both anatomic sites fall into the same anatomic classification, as defined by the code descriptor for code 14041, the defects do not have contiguous margins and represent separate and distinct defects. Some payers may require the use of modifier 59.

Example 5

Excision of nasal basal cell carcinoma (BCC), cheek scar, BCC of the forehead, and nevus of the chin.

14060   Adjacent tissue transfer (excision of nasal BCC and nasal flap)

14040 51   Adjacent tissue transfer (excision of cheek scar and two Z-plasties)

11641 51   Excision, malignant lesion, forehead

11440 51   Excision, benign lesion, chin

12052 51   Layered closure of forehead and chin lesions

In this example, there are four excisions performed: two repaired with layered closure and two repaired with adjacent tissue transfers. If lesion excisions and flap closures are performed at the same session, each procedure should be reported separately. Some payers may require the use of modifier 59 to convey that the two excisions were separate procedures, unrelated to the excisions that were components of the flap procedures.

NOTE: The excision of the nasal basal cell carcinoma is included in code 14060and is not reported separately.

CPT Assistant © Copyright 1990–2008 American Medical Association. All Rights Reserved 

Karen Maloney, CPC 
Data Quality Specialist


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## ljk7172

Thank you Karen.  What I am gathering is that since this was the same lesion (Moh's excision) is that the 2 different flaps would be added together.

Sincerely,
Lissa


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## magnolia1

Lissa,

Is the second flap being performed to correct a defect incurred while obtaining the tissue for the first flap?

Karen Maloney, CPC
Data Quality Specialist


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