General Surgery Coding Alert

Question: The surgeon documented rotation of temporalis muscle flap, rotation of sternocleidomastoid flap, and rotation of postauricular skin flap. How should I code these procedures?


Illinois Subscriber


Answer: The surgeon described rotated muscle flaps, which you should report using 15732 (Muscle, myocutaneous, or fasciocutaneous flap; head and neck [e.g., temporalis, masseter muscle, sternocleidomastoid, levator scapulae]). Documentation for 15732 should clearly describe a rotated muscle flap in meticulous detail. The op report should detail how the surgeon created the muscle flap and performed the closure.

If the surgeon did indeed create three flaps, use modifier 59 (Distinct procedural service) on the second two flap codes. The modifier designates the additional flaps as occurring on separate sites. You would report 15732-59 x 3 to an insurer that accepts units.

For payers that do not process units, line itemize each flap as:

- 15732 

- 15732-59

- 15732-59. Don't forget: You may separately report repair of the donor site. Although you do not indicate this procedure in your description, make sure you capture this added value if your surgeon performed this work.

When coding muscle, myocutaneous or fasciocutaneous flaps, pay attention to the flap's donor site, not the defect site. So the flaps come from the head and neck. The defect site (the inner ear) is not important. In contrast, code free grafts (15050-15321, 15340-15366, 15420-15431, 15757) and adjacent tissue transfers (14000-14350) based on the defect site.