# rotational flap help??



## BFAITHFUL

I have an op report that I would like your opinions regarding a rotational flap?
Sorry it's so lengthy!!!       
Dr. wants to bill cpt 14060 but I think we can bill for more, I see Z-plasty, bilobed flap, etc…?

DX:  Nasal defects status post Mohs excision of basal cell carcinoma.

Operative Note:

Attention was directed initially to removal of dressing of the right side of the nasal tip.  This dressing was removed revealing a defect measuring 1.5cm x 1.4cm on the right side of the nasal tip extending through the nasal alar cartilage.  The facial area was prepped with a dilute Betadine solution and draped in a sterile fashion.   A paper template was created for a rotation flap to filling this defect a flap measuring approx. 1.5cm in width x 3.5cm in length.  This is drawn out with the skin marking pencil based laterally rotating the tissue from superior to inferior on the nasals tip.  Additionally, a secondary lobe for this flap was then outlined as well using the paper template to filling the defect created by the first flap.  This was somewhat laterally on the right side of the nose also inferiorly based.  The patient's nasal area was anesthetized through the use of injections of 1% Xylocaine with epinephrine local anesthetic solution as well as the medial aspect of the right cheek and the inferior aspect of the forehead and then appropriate waiting period was observed to aid in adequate hemostasis.  The wound was thoroughly cleansed on thenar aspect using sterile cotton tip applicator stick dipped in Betadine solution and charred material from the previous days Mohs surgery was scraped with a #15 scalpel blade until clean.  The template was agin used to check the rotation of the tissue.  The flap was then created through the use of sharp dissection.  Hemostasis was achieved through the use of electrocautery.  The flap was then rotated into the position to fill the defect on the tip of the nose and sutured along with inferior and medial aspects using interrupted sutures of 6-0 nylon.  The  secondary flap was then marked out with the paper template once again and this flap was placed inferiorly and extended more towards the radix of the nose measuring approximately 3.5cm x 1.3cm.  This following checking with template the flap was created through the use of sharp dissection and rotated distally secondary defect from the original flap.  Hemostasis was achieved through the use of an electrocautery and the wound was sutured to the first flap and to fill the defect.  Left via the first flap using interrupted sutures 6-0 nylong.  The remaining defect on the right side of th nose on the superior aspect of the nasal bridge was the nstarted to be repair from the superior aspect by the nasal radix.  The subcutaneous tissues and dermis were approximated through the use of interrupted sutures of 5-0 chromic catgut and the skin edges were approximated through the use of running and interrupted sutures of 6-0 nylon superiorly and 5-0 nylon as moved inferiorly.  The base of the flap was also closed using interrupted sutures 5-0 nylon as moved inferiorly.  The base of the flap was also closed using interrupted sutures 5-0 nylon.  This left a defect approximately 1cm x 2cm, which could not be closed.  The skin edges were undermined in all directions through the use of sharp and blunt dissection.  It was elected to the ncreate superiorly base flap on the left based on the left side of the nasal bridge area and rotate that laterally across the nasal bridge to filling the defect of the right side of the nasal bridge and a Z-plasty was used at the base of this flap to filling the remaining soft tissue defect.  Minimal tissue excision was carried out.  The tip of the secondary flap as this was felt to be tissue, which was not needed further repair.  The skin edgews were then approximated through the use of interrupted sutures of 5-0 nylong and this affected a very good closure with good nasal contour.  The area was cleansed with a saline solution and dressed with bacitracin ointment dressing.  The patient tolerated the procedure well and was transferred the recovery room in a satisfactory condition.


----------



## FTessaBartels

*Boy ... this is complicated*

Okay ... after reading this three times I come up with

1) defect of 1.5 x 1.4 = 2.1 cm   PLUS flap of 1.5 x 3.5 = 5.25 cm  // added together equal 7.35 cm for the first repair of the original defect.  *14060*

2) repair of secondary defect from creating the first flap
    3.5 x 1.3 = 4.55 cm   *14060-59*

3) repair of third defect from creating the second flap
    1c x 2cm = 2 cm *14060-59*

And, of course, now I'm second guessing myself because I just cannot remember if I'm supposed to be adding all these square centimeters together to come up with 14061 or if I'm supposed to code each separately with the -59 modifier to indiciate separate incisions.  

I've put in a call to our senior surgical coder who handles plastic surgery ... will update when I get info.

Hope that helps.

F Tessa Bartels, CPC, CEMC


----------



## graciejean

*ICD-9 code for Moh's defect*

What ICD-9 code is for Moh's defect (ie. nose)?


----------



## lissalea

*icd code*

738.xx with v10.8x


----------

