# coding flap & graft??



## BFAITHFUL (Oct 17, 2010)

DX: squamous cell carcinoma of the nose and basal cell carcinoma of the right nasal bone

Procedure:

Patient who has had squamous cell carcinoma completely destroyed his right nose.  In addition, a separate basal cell carcinoma was identified superiorly.  The patient has been informed the various treatment choices and has been decided that the patient has a nasolabial fold flap was used to resurface not only the nose and the cartilage of the nose.  The excision medially was being done as the patient had a slight positive inferior margin and residual basal cell carcinoma on the nasal dorsum, where the patient had a shave biopsy and partial basal cell removed.  

patient first had the excision of right nose including lower cartilage skin, mucoperichondrium, and septum.  Once this excision was completed then the patient had the specimen tagged and then previous basal cell carcinoma excised.  This nasal bridge defect was closed with 7-0 nylon on the nasal bridge.  A complete undermining of the mucosa under the right upper lateral cartilage was done.  The patient then had the mucoperichondrial flap raised off the septum and rotated medially so the flap touched the vestibular lining of the right ala.  This alar intranasal defect was closed with deep suture of 4-0 vicryl and external sutures of 5-0 nylon.  The patient having the integrity of the mucosa lining completed.  Then, the patient had the back area grafted with a full thickness skin graft obtained from right ear, which was secured with the sutures of 0 Prolene.  The patient then had the medial nasal wound resected.  A small piece of silicone and then 4cm x 5mm articular cartilage supported the right ala.

The patient then had the nasolabial skin flap rotated laterally so that it could be appropriately cover the skin defect to prevent a postoperative contraction.  The nasolabial fold flap was raised from the nasolabial fold 2cm in width up to the base of the ala.  The flap was then rotated across the midline of the nose and secured to the perichondral flap with sutures of 5-0 nylon.  The rotation of the flap was done with the closure of the nasal dorsum, where a previous basal cell was removed.  This was accomplished with nasolabial fold flap rotation.  The dead space was closed after the cartilage graft was secured in the nasal pocket with multiple sutures of 7-0 nylon in the skin margin.  The patient then had septal flap rotation left open and there is no compromising skin flap, which was attached to the nose.   Nasal pack was placed on the nose.  the patient had a complete restoration of the nasal mucosal lining.  


I'm thinking 14060, 21235, full thickness graft code 15xxx, & Im thinking another advancement flap code 140xx?


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## BFAITHFUL (Oct 22, 2010)

Any takers on this?


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## LCRUZ515 (Oct 22, 2010)

I would bill for 14060 for the first procedure and 15260 for the second procedure.


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## BFAITHFUL (Nov 1, 2010)

what about CPT 21235? cartilage taken from ear?  my take on  this is he isn't very clear, he states "patient had back area grafted with a full thickness skin graft obtained from right ear"  so he says "skin" not "cartilage"  but then he goes on to state, 
"a small piece of silicone and then 4cm x 5mm articular cartilage supported the right ala"

Thanks


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