# Question about Closure with adjacent tissue transfer



## tholcomb (Nov 21, 2016)

Good morning Fellow Coders,

Question about Closure with adjacent tissue transfer of myofascial gluteus flaps, 110 square cms x 2 sides 220 sq cms total would cpt code would cpt 15734 be appropriate see op note below.


OPERATIVE FINDINGS: 
The patient was found have a large pilonidal cyst with multiple sinus openings. 
The cyst extended down to the presacral fascia in the midline. 
*

The patient was brought to the operating room, and after the induction of 
general anesthesia, was placed in the prone jack-knife position upon the 
operating table. Each of the sinus openings was probed with a blunt malleable 
probe. The cyst openings were then injected with 50% dilute methylene blue dye 
to help identify the cyst wall intraoperatively. The skin was infiltrated with 0.5% Marcaine with epinephrine to aid in post-operative analgesia. 
A longitudinal elliptical incision was made in the midline encompassing all of 
the sinus openings. Bovie electrocautery was used to carry the incision 
full-thickness through the skin and subcutaneous tissues, excising the cyst in 
its entirety. The dissection was carried down to the presacral fascia where the 
cyst was is seen to extend. The cyst was excised in its entirety en bloc with its overlying ellipse of skin. It was passed off the table as specimen. Hemostasis was obtained using Bovie electrocautery. The wound was irrigated with sterile saline and then dried. 
At this time, we detached both the right and left gluteus muscles from their 
insertion on the sacrum using Bovie electrocautery. The myofascial flaps were 
raised approximately 5 cm laterally for each flap. This included development of the flaps by dividing tissue deep to and superficial to the muscle. The midline defect, which 
consisted of only presacral fascia and the midline sacrum in the middle was 
approximately 11 x 10 cms. We used these muscle flap to cover this area by 
suturing the 2 advanced myofascial flaps to one another using a running 0 
Vicryl suture in the midline. Once these were sutured 
together, the presacral fascia and sacral bone were completely covered with the 
myofascial flaps in the midline, allowing for better blood supply for healing of 
the large wound and decreased depth of the gluteal cleft. 
The wound was again irrigated with sterile saline and then dried. Hemostasis 
was excellent. A 10 flat JP drain was placed in the subcutaneous space and run out through a separate stab incision in the left buttock.
The drain was sutured to the skin with a 3-0 Nylon stitch. The subcutaneous tissue was reapproximated using 2-0 Vicryl in a 
running stitch. The skin was closed using 4-0 Monocryl in a running 
subcuticular stitch. Mastisol, Steri-Strips, and then a sterile dressing were 
applied. All sponge, needle, and instrument counts were correct at the end the 
case. The patient tolerated the procedure well, was extubated, and brought to 
the recovery room, awake and in stable condition.


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## cpc2007 (Dec 9, 2016)

Hi, I agree with your code 15734 for the gluteus muscle flap.  Because the physician states that he creates two separate flaps (one on the left and one on the right) and then advances them and brings them together to close the defect, you can actually code 15734, 15734.59 (to give credit for both flaps).

Thanks,
Kim


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