# Reconstruction of Mandibular defect



## mireya77 (May 29, 2013)

I'm new to this specialty. Can anyone help with coding this procedure? There were actually two physicians involved with this.

This what they would like billed each:

20969 - 62, free osteocutaneous flap with microvascular anastomosis;other than iliac crest, metatarsal, or great toe

21198 x 4 osteotomy, mandible, segmental;
21998 x 4 - 80

Six of the 21198's are being billed for the osteotomies performed to the fibula. I feel this is part of the harvesting included in 20969. The physicians do not agree.

I would appreciate any feedback or suggestions on how to code this.


PREOPERATIVE DIAGNOSIS:
Squamous cell carcinoma of right floor of mouth and mandible.

POSTOPERATIVE DIAGNOSIS:
Squamous cell carcinoma of right floor of mouth and mandible.

PROCEDURE:
1. Reconstruction of right floor of mouth and mandibular defect with a free
fibular osteo-septo-cutaneous flap.
2. Fibular osteotomies times 8.
3. Adjacent tissue transfer intraoral greater than 30 square cm.
4.  Mandibular osteotomy times 2.

ANESTHESIA:
General.

ESTIMATED BLOOD LOSS:
150 mL.

COMPLICATIONS:
None.

DESCRIPTION OF PROCEDURE:
The patient was placed in supine position under general anesthesia.  The ENT
service had completed a tracheostomy, bilateral neck dissections.  Dr. X began elevating the right fibular free flap with a skin paddle, in the meanwhile, I worked at the head to further expose the vessels in the right neck, the facial artery and common facial vein and then once full exposure of the mandible had been obtained we applied a cutting guide to the right proximal body just anterior to the oblique line and secured with 2 monocortical screws. I then placed an external fixator on the mandible temporarily to stabilize it using 2
pins on either side of the proposed osteotomy for the mandible.  We then used a
sagittal saw to complete the osteotomy on the right side just proximal to the
oblique line.

The ENT service had removed the canine on the left side of the mandible and we
drew a line vertically just mesial to the first premolar and then using a
reciprocating saw completed the osteotomy in this location.  The specimen was
then removed.  The external fixer was maintained until the reconstructive plate
had been applied along the lower border later in the case and then it was
removed.  Once the fibular free flap had been completely elevated, we performed
a total of 8 osteotomies to repair it for transfer to become the  reconstructed
mandible.  There was a total of 4 segments of fibula with an intervening pedicle
segment to allow us to perform a double barreled reconstruction, 2 segments on
the upper barrel and 2 segments on the lower barrel with a skin paddle as well.
The flap was harvested using medium clips in the leg and brought up to the head
and neck area.

Using a 2.5 prebent reconstructive plate we fixated the lower 2 segments of the
double barrel free fibula into position, into the plate and then secured the
plate to the left and right side of the mandible.  We had good bony apposition.
At this point, we used simply monocortical screws for fixation.  We then brought
in the microscope and prepared the donor and recipient vessels under the
microscope using standard microsurgical technique, removing the adventitia.  We
checked the flow in the facial artery and it was excellent and then performed a
3.0 mm venous couple for the venous anastomosis and then hand sewn 8-0 nylon
arterial anastomosis.  When the clamps were removed, the flap perfused well and
had excellent bleeding from the skin paddle edge.  We then using 1-0 plates
fixated the upper barrel of the double barrel fibula to itself and to the native
mandible bone proximally and distally.

Following this, we irrigated the leg copiously, placed a #15 drain sutured to
the skin with 3-0 nylon and then closed the muscle fascia with 2-0 PDS, the
dermis with 3-0 PDS and 3-0 nylon was used in the skin.  Ultimately we applied a
Xeroform, fluffs and Ace wrap dressing on the leg donor site.  The neck was
closed with 2 #10 drains  inserted through separate stab incisions that were
sutured to the skin with 3-0 nylon and we closed the platysma with 3-0 Vicryl
and the skin with 4-0 nylon.  The drains were placed to bulb suction.
Intraorally, we irrigated copiously and then inset the 7 x 5 skin paddle with
4-0 Vicryl horizontal mattress sutures.  At the end of the case we changed the
tracheal tube to a #6 cuffed Shiley tracheal tube and then sutured it to the
surrounding skin with 3-0 Prolene and then we inserted a Dobbhoff feeding tube
and taped it to the nose.  At the end of the case in the perforator location of
the skin paddle once we had marked with 5-0 Prolene there was an excellent
Doppler signal.  The patient tolerated the procedure well.  There were no
complications.


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## nateslidder (May 17, 2018)

*Natalia*

I agree with you on the osteotomies. It is included with the harvest. I do not bill it either.


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