General Surgery Coding Alert

When surgeons create tissue flaps to repair defects created by excision or other injury, coding the scenarios can get messy.

Read on to learn three steps to focus your choices and make sure you pick the right code every time.

Tip 1: Know What's Included

Sometimes your surgeon needs to move beyond simple, intermediate or complex repair to close a defect. That's when you might see documentation for various advancement flaps such as those described by codes 14000-14302 (Adjacent tissue transfer or rearrangement ...). CPT^® distinguishes these codes by anatomical site and size.

"The defect requiring the graft might occur by various means, such as by accidental laceration, or by your surgeon excising a lesion," explains Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, director of operations with Encounter Telehealth in Omaha, Nebr.

To use these codes, the surgeon must describe a repair that involves creating incisions and rearranging tissue in a form such as Z-plasty, W-plasty, V-Y-plasty, rotation flaps, island flaps, or other specific arrangements.

Limitation: CPT^® instruction asserts that these arrangements must be intentional to close the defect. The codes "do not apply to direct closure or rearrangement of traumatic wounds incidentally resulting in these configurations."

Also, "documentation that the surgeon undermines adjacent tissue to accomplish a closure does not, by itself, justify using these codes," Joy cautions. The surgeon might undermine adjacent tissue to accomplish a complex closure that you'd report with a code from the range 13100-13153 (Repair, complex...). "You must also see documentation of specific incisions and tissue rearrangement to use codes in the range 14000-14302," Joy says.

Excision included: If your surgeon excises a benign or malignant lesion that requires one of these adjacent tissue rearrangements to repair the defect, you shouldn't separately bill the excision code such as 11606 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm).

"This can be confusing for coders, because the rules are different for various types of repairs," says Joy. Here are the differences:

• For lesion excision plus simple repair, you should bill only the excision code
• For lesion excision plus intermediate or complex repair, you should bill both the excision and the repair codes
• For lesion excision plus adjacent tissue transfer, you should bill just the flap code, not the lesion excision code.

Tip 2: Understand Add-Ons

Sometimes when the surgeon creates an advancement flap to repair an initial defect, he creates a "secondary" defect at the site of the flap used for reconstructing the initial defect.

Opportunity: If a secondary defect also requires a skin graft, you should additionally report that work. If both involve adjacent tissue transfers at the same anatomic site, you should add the defects together to select a single code. "The number one documentation error that occurs with adjacent tissue transfers is that the surgeon does not describe the size of the secondary defect - which may even be larger than the primary," Joy says.

Watch for 'oversize' flaps: Codes 14000-14061 describe defects up to 30 sq cm in size at specific anatomic sites. If the surgeon uses a larger surface area, you should turn to codes 14301 and +14302 (Adjacent tissue transfer or rearrangement, any area ...).

Although codes 14000-14061 are site-specific, you should use 14301 for an adjacent tissue transfer between 30.1 and 60 sq cm at any anatomic site. If the graft is even larger than 60 sq cm, you should add +14302 (...each additional 30.0 sq cm, or part thereof [List separately in addition to code for primary procedure]) for each additional 30 sq cm or part therof.

Remember: If your surgeon doesn't document the secondary defect size, you must code only from the primary defect, and that can mean missing out on legitimate increased reimbursement for these larger size codes.

Tip 3: Don't Confuse 'Other' Flaps

Not every rearrangement flap reports to a code from the range 14000-14302. "One feature that distinguishes flaps in the range 14000-14302 from other flaps, is that they're always from immediately-adjacent areas," Joy says.

In addition to not being limited to "adjacent" tissue, other codes also describe flaps that have distinct features, such as a specifically-identified and dissected axial vessel, or neurovascular pedicle, or microvascular anastomosis. For those procedures you need to turn to codes in the range 15740-15788.

For instance, if your surgeon creates a 20 sq cm subclavian-vein pedicle flap to repair a distant injury to the right axilla, should you report 15740 (Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel) not 14041 (Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm).