General Surgery Coding Alert

Focus on vascular pedicle to choose correct code.

If you haven't taken the time to master the CPT^® 2018 code changes for pedicle-flap repairs, you could already be to losing big pay.

With two new codes, one deleted code, and a few new CPT^® text notes in the "Flaps (Skin and/or Deep Tissues)" section, we have the expert advice you need to make sure you stay on track with your pedicle-flap coding this year and beyond.

Terminology tip: A pedicle flap is a type of nonadjacent tissue transfer that initially remains attached to the donor-site blood supply. The surgeon cuts a "stalk," or pedicle of tissue, that includes a flap the proper size and shape to repair a defect that is not contiguous with the donor site, such as on the forehead or nose tip. The surgeon then maneuvers the flap to the repair site, still attached by the pedicle to the donor site, and later cuts the pedicle free. Pedicle flaps can refer to skin or deep-tissue transfers, and you might see the procedure called "attached flap" or "tubed pedicle."

Focus Muscle Flap Coding

CPT^® 2018 added new code 15733 (Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae)).

On the other hand, you can say goodbye to 15732 (Muscle, myocutaneous, or fasciocutaneous flap; head and neck (eg, temporalis, masseter muscle, sternocleidomastoid, levator scapulae)), which new code 15733 replaced.

To make sure you understand the switch, CPT^® 2018 added this text note under code 15731: (15732 has been deleted. To report myocutaneous or fasciocutaneous flap, use 15733).

See the difference: What's changed between the two codes is that 15732 identified some examples of muscles that might be involved in the procedure, while 15733 specifies a named vascular pedicle. New code 15733 also makes the parenthetic note "i.e." (that is) instead of the old 15732 code's "e.g." (for example).

What this means: "To report 15733, the surgical note must name the vascular pedicle," says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, director of operations with Encounter Telehealth in Omaha, Nebr. "However, the list in the code definition is not exhaustive, it just lists examples," she says.

CPT^® 2018 adds another text note concerning the new code: (For muscle, myocutaneous, or fasciocutaneous flap of the head or neck, use 15733).

Other sites: For muscle, myocutaneous, or fasciocutaneous flaps of other anatomic sites that do not involve a pedicle, look to the following codes:

• 15734 (... trunk)
• 15736 (... upper extremity)
• 15738 (... lower extremity).

Coder tip: Use the donor site to choose the correct code in the range 15733-15738.

Distinguish Specific Vascular Pedicle Codes

CPT^® 2018 also clarifies facial pedicle-flap coding by adding a new code and some text notes.

The new code is 15730 (Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s)).

"Code 15730 describes a very specific type of procedure, called a zygomaticofacial flap, which requires that the surgeon preserve the vascular pedicle," Joy says.

In this procedure, the surgeon dissects and localizes the cutaneous zygomatic branch from the high-cheek area of the face. The surgeon uses this excision to perform an island axial pattern flap, typically to repair defects of the nose or upper lip.

Different: If the surgeon documents the specific pedicle flap procedure preserving the cutaneous zygomatic branch, don't report a more general pedicle-flap code such as 15574 (Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet) or 15576 (Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral).

Lose pay: Missing the 15730 option and using the more general code instead could cost your surgeon almost $150 (15730 non-facility price $486, versus $337 for 15576, 2018 Medicare Physician Fee Schedule, conversion factor 35.9996).

Although 15730 is the only new code in this range, CPT^® 2018 added some text notes to clarify how you should use 15731 (Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap)).

Named pedicle: For a forehead flap with a named vascular pedicle, you should use 15731 instead of less specific-code 15574. The CPT^® text note states:

(For anterior pericranial flap on named vascular pedicle, for repair of extracranial defect, use 15731).

Another new text note warns coders to move out of the 15570-15738 code range entirely for other, similar types of repairs that are actually different procedures such as advancement flaps without a named vascular pedicle. The note states:

(For repair of head and neck defects using non-axial pattern, advancement flaps [including lesion] and/or repair by adjacent tissue transfer or rearrangement [eg, Z-plasty, W-plasty, V-Y Plasty, rotation flap, random island flap, advancement flap] see 14040, 14041, 14060, 14061, 14301, 14302).

Review Pedicle Flap Rules

That final note reminds us that pedicle flaps are a specific type of repair service distinct from adjacent tissue transfer, free flaps, and skin grafts. As such, you need to keep in mind the unique and peculiar coding rules for pedicle-flap procedures.

3 steps: A pedicle flap repair involves forming a pedicle at the donor site, usually sectioning the flap at a later time, and finally completing the transfer of the flap to the recipient site. The steps may take place in a single surgical session, but are usually staged through multiple procedures over time.

You can distinguish codes by anatomic site for the formation codes (15570-15576 (Formation of direct or tubed pedicle, with or without transfer ...)) and the delay/sectioning codes (15600-15630 (Delay of flap or sectioning of flap (division and inset ...)). You should use 15650 (Transfer, intermediate, of any pedicle flap (eg, abdomen to wrist, Walking tube), any location) when the surgeon transfers the pedicle flap to the recipient site at an operative session separate from the earlier pedicle formation surgery. If the surgeon completes the transfer in the initial session, the formation codes 15570-15576 include that work.

Donor vs. recipient site: When you use a code from the range 15570-15576, knowing whether to use the donor or recipient site to choose the code can be confusing.

Do this: For immediate transfer cases, select one code from the range 15570-15576 based on the recipient site. For delayed transfer cases, select the code from the range 15570-15576 based on the donor site.

Capture extra services: Unlike adjacent tissue transfer codes (14000-+14302), pedicle flap formation codes 15570-15576 don't include lesion excision. You should separately report an excision using a code from the range 11600-11646 (Excision, malignant lesion including margins ...) if the surgeon performs the work prior to forming the pedicle flap.

Similarly, you can separately code donor site repair if it requires procedures beyond primary closure, such as skin graft or local flaps.