# Ugh! flap takedown



## sgremmels (Mar 9, 2017)

I originally posted this in plastics but ENT's often do the reconstruct portion. so here goes... I need some serious help in understanding what codes other than 15630 should be used.  14040 states an incision must be made and the pedicle was incised... does that count?  If you have anything to offer, I would appreciate any and all help!  Thank you!!!
Patient had MOHs surgery by derm and this is stage II nasal tip reconstruction by the ENT:


 A transection point was selected. Next working on the proximal end of the flap, skin was elevated with a 2 mm cushion of fat underneath it. This allowed the excess tissue below to be carefully removed. This included scar and a small amount of muscle. An inverted V inset site was created. This allowed for some thin scarred tissue to be removed from the forehead proper. The proximal end of the forehead flap was able to be inset with good visual contour. After this was trimmed to proper size, it was secured using ................. Attention was next turned to the distal portion of the flap covering the nasal tip. Again markings were made on the nasal tip indicating a generous 1 cm attachment area that would not be violated during the procedure. This was slightly tilted toward the left as the left side appeared very cosmetically favorable whereas the right side of the flap was a bit proud and would benefit from debulking. The skin was elevated from this distal end leaving a cushion of 2 mm of fat.This allowed the residual scar and remaining tissue to be trimmed from the nasal tip. On the right side the flap was carried down slightly lower in accordance to the markings made earlier. The edges were carefully refreshed and the receiving skin undermined for mobility. A slight revision of the edge of the superior portion of the nasal tip was also created to allow for access to better appearing skin and a smooth cut surface that was symmetric. This flapwas carefully trimmed to match the recipient site and required numerous revisions to have an exact fit. Once achieved for both size and level, the skin was reapproximated .....................


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## JenniferB7 (Mar 11, 2017)

In your case, it looks like your surgeon is doing a 2 stage paramedian forehead flap. Stage 1 (previously performed) would have been coded with CPT code 15731 for forehead flap with preservation of vascular pedicle. This procedure is commonly performed in 2 stages, which is also supported by your note indicating that this is stage II. This website, http://emedicine.medscape.com/articl...51-overview#a3, gives some awesome explanations in to the flaps, including this one (look for the heading, Paramedian Forehead Flap). Just know it also contains some graphic pictures of the procedures. 

For Stage 2 (your current operative note), CPT code 15630 is correct. Make sure you apply modifier 58 to indicate this is a staged procedure, otherwise it will be bundled into the global period for 15731. I don't see anything showing a flap was advanced, rotated, or transferred to justify coding an adjacent tissue transfer code (14040-14061). It looks like the surgeon simply elevated, thinned, and trimmed the margins of the flap created in stage 1, in which case, you would only code 15630-58.

Here are some references I have found helpful:


The Coder's Desk Reference (https://www.aapc.com/medical-coding-...reference.aspx)

The Illustrated Guide for Otolaryngology Coding (https://www.supercoder.com/illustrat...gy-coding-book) to be helpful.

Hope that helps and welcome to ENT!  

Sincerely,

Jennifer M. Connell, CPC, CPCO, CPC-P, CPB, CPMA, CPPM, CPC-I, CENTC


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## sgremmels (Mar 12, 2017)

*Thank you!*

Thank you so much Jennifer! I really appreciate the assistance and I will check out all the websites you noted.


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## JenniferB7 (Mar 13, 2017)

You are very welcome!

Jennifer


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