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1

A 41-year-old woman comes to the office for follow-up examination after undergoing reconstruction of the left breast with an implant. She has an upper pole contour depression and desires correction. She has been preauthorized for fat grafting from the abdomen to the upper pole; 25 mL is injected into the upper pole. Which of the following is the most appropriate Current Procedural Terminology (CPT) code?

11954 subcutaneous injection of filling material (e.g., collagen) over 10.0 mL
15877 suction-assisted lipectomy; trunk
19380 revision of reconstructed breast
20926 tissue grafts, other (e.g., paratenon, fat, dermis)
A) 15877 and 11954
B) 15877 and 19380
C) 19380
D) 20926
E) 20926 and 19380

D) 20926

Similar to skin grafting, fat grafting involves a donor site as well as graft and recipient preparation. Fat is harvested, and donor site is closed and dressed. Fat graft is processed and injected into the recipient site. Fat grafting is reported with code 20926 (tissue grafts, other [e.g., paratenon, fat, dermis]) and includes the following:

Harvest of the fat graft material by any method (e.g., syringe, suction- assisted lipectomy, incision)
Closure of the donor site, if indicated, with appropriate dressing
Processing of fat graft material
Injection of fat graft into recipient site
Dressing of recipient site
90 days of routine postoperative care
Code 20926 is not anatomical site-specific, nor is it volume dependent. Thus, both the injection of 50 mL of fat into the cheek concavity and injection of 500 mL of fat into the thigh for correction of contour irregularities are coded as 20926. This code is used for each anatomical area injected; thus, if both breasts had fat grafting, the Current Procedural Terminology (CPT) codes would be 20926 and 20926-59, because the second breast is recognized as a separate and distinct procedure.

Code 15877 (suction-assisted lipectomy; trunk) is not coded separately because harvest of the graft by any method is included in 20926.

Subcutaneous injection codes (11950–11954) describe the injection of “off the shelf” products such as collagen. These do not involve the harvest of tissue, and hence neither donor site nor postoperative care is involved.

Code 19830 (revision of reconstructed breast) may be appropriate if a large area or multiple areas of a reconstructed breast are grafted, because it may be better described as a “revision of the reconstructed breast.” Currently, however, there is no uniform established minimum volume to be considered sufficient to warrant use of code 19830 instead of 20926. Preauthorization for insurance reimbursement should be done for all fat grafting procedures, because not all payers will cover them, since there is no “functional improvement.”

2

A 25-year-old man is evaluated after sustaining a left zygomaticomaxillary complex (ZMC) fracture. On exploration of the fracture through the upper buccal sulcus, left brow, and left trans-conjunctival incisions, the fracture crosses the infraorbital foramen, and the left orbital floor fracture is significantly depressed and displaced. Open reduction and internal fixation (ORIF) of the orbital floor and ZMC fractures is performed. Which of the following is the most appropriate CPT code for this patient?

21360 ORIF malar fracture only
21365 ORIF of “complicated” malar fracture only
21390 orbital blowout fracture repair, periorbital approach with alloplastic or other implant
A) 21360
B) 21365
C) 21390
D) 21360 and 21390
E) 21365 and 21390

E) 21365 and 21390

21365 is the appropriate code for the zygomaticomaxillary complex (ZMC) fracture repair since the repair requires multiple incisions and the fracture crosses the infraorbital foramen. The orbital floor repair is not considered “bundled” with the repair of the ZMC fracture and should be billed separately as a distinct procedure.

21360 is not the appropriate code for this complicated ZMC fracture. 21390 is correctly added to this code, however.

21360 is the appropriate code for a simple repair of a ZMC fracture and does not include reduction and repair of the concurrent orbital floor fracture.

21390 is not the appropriate code without 21365.

21365 is the appropriate code for the ZMC fracture repair, however, this option omits the code for the reduction and repair of the orbital floor fracture.

3

A 35-year-old man is evaluated for a history of sleep apnea and nasal airway obstruction. Physical examination shows a narrowed middle vault with an internal valve of less than 10 degrees and a septum that deviates along the maxillary crest to the left, narrowing the airway. The operative plan is for spreader grafts from the septum, and submucous resection of the deviated portion of the septum. Which of the following is the most appropriate Current Procedural Terminology (CPT) coding for this procedure?

20912 Septal cartilage graft
30410 Rhinoplasty, primary; bony pyramid, lateral and alar cartilages and/or tip
30420 Rhinoplasty, primary; bony pyramid, lateral and alar cartilages and/or tip, including major septal repair
30465 Repair of nasal vestibular stenosis
30520 Septoplasty or submucous resection with or without cartilage scoring, contouring, or replacement with graft
A) 20912 and 30420
B) 20912 and 30465
C) 30410 and 30465
D) 30420 and 30465
E) 30465 and 30520

E) 30465 and 30520

In this patient, the most appropriate code is one that addresses the vestibular stenosis only: 30465. The more inclusive codes of 30410 and 30420 include surgery involving the lower lateral (alar) cartilages to address tip issues, and, in the case of 30410 and 30420, work on the bony pyramid as well; none of which are a component of the procedure undertaken, which is limited to addressing the internal nasal valve narrowing.

CPT code 30520 is most appropriate to use for the septoplasty because the harvesting of cartilage is included in the submucous resection surgical field, and, as a result, cannot be coded separately as a septal cartilage graft harvest. If one were not performing a septoplasty, then the most appropriate code would be 20912 for the septal graft harvest to be used for the spreader grafts.

4

A 67-year-old woman comes to the office because of a 1-year history of a 2-cm basal cell carcinoma of the cheek. The lesion is excised with a 5-mm margin leaving a 3.0 × 3.0-cm defect. The wound is closed with a rhomboid flap. Which of the following is the most appropriate current procedural terminology (CPT) code for this procedure?
CPT code Description
11100 biopsy of skin (including simple closure); single lesion
11643 excision, malignant lesion including margins face, 2.1 to 3.0 cm diameter
13132 repair, complex, cheek 2.6 to 7.5 cm
14040 adjacent tissue transfer or rearrangement cheeks defect 10 cm2 or less
14041 adjacent tissue transfer or rearrangement cheeks defect 10.1 cm2 to 30.0 cm2
A) 11100
B) 11643
C) 14041
D) 11643 and 13132
E) 14040 and 11643

C) 14041

The most appropriate current procedural terminology (CPT) code for this procedure is 14041, adjacent tissue transfer or rearrangement of cheek defect. In this case, the rhomboid flap is most accurately considered an adjacent tissue transfer. 11643, excision of a malignant lesion is not separately reportable with codes 14000-14302, and separate reporting would be considered unbundling.

If the lesion were excised and closed by wide undermining, only 11643 and 13132, complex closure and excision of malignant lesion, would be used. In this case, the closure consisted of more than simple undermining and thereby closure with an advancement flap is a more appropriate choice. Excision of benign or malignant lesion, excisional preparation of a wound bed, or debridement of an open fracture or open dislocation are not included in complex repair codes.

The choices of 11643 (excision of malignant lesion) or 11100 (biopsy of skin) both under-code based on the extent of the procedure in the described scenario.

5

A 45-year-old man is referred for scalp reconstruction after undergoing Mohs micrographic surgery for removal of squamous cell carcinoma of the scalp. The defect measures 5 × 10 cm. The scalp is reconstructed with a rotation flap measuring 20 × 30 cm with a 5 × 2-cm split-thickness skin graft on the secondary donor defect. When assigning a current procedural terminology (CPT) code for the adjacent tissue transfer, which of the following is the correct area to use?
A) 50 cm2
B) 600 cm2
C) 650 cm2
D) 810 cm2
E) 1000 cm2

C) 650 cm2

Adjacent tissue transfer is one of the most common procedures performed by plastic surgeons, and accurate coding is essential for accurate reimbursement, insurance integrity, and ethical reasons.

The most appropriate method for calculating the area is to add the area of the defect to the area of the flap. The area of the defect is considered the “primary defect,” and the flap alone is considered the “secondary defect.” It is the combination of these that determines the area on which the current procedural terminology (CPT) codes are based. In this case the defect measures 5 × 10 cm, or 50 cm2. The flap itself measures 20 × 30 cm, or 600 cm2. Therefore, the total area used to assign the correct CPT code is 650 cm2.

The skin graft is over part of the secondary defect, which is already covered by the secondary defect measurement. However, the skin graft is an additional code that should be added to the codes for adjacent tissue transfer.

6

During breast reconstruction with a free transverse rectus abdominis musculocutaneous (TRAM) flap, the axillary vessels are dissected, and the anastomosis is performed using an operating microscope. During flap elevation, an umbilical hernia is encountered and repaired. The TRAM flap is then contoured and inset to form the new breast. The abdomen is then closed. In addition to 19364 (breast reconstruction with free flap), which of the following is the most appropriate Current Procedural Terminology (CPT) coding for this procedure?
A) 15847 (abdominoplasty)
B) 49585 (repair of umbilical hernia, reducible)
C) 49585 (repair of umbilical hernia, reducible), 15847 (abdominoplasty), and 69990 (use of operating microscope)
D) 69990 (use of operating microscope)
E) No additional coding is necessary

B) 49585 (repair of umbilical hernia, reducible)

The Current Procedural Terminology (CPT) code set is maintained by the American Medical Association through the CPT Editorial Panel. The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services provided and procedures performed among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.

CPT codes group together portions of an operation or procedure. Reporting or billing for each individual part of a procedure is legal and known as “unbundling” the procedure. The free flap breast reconstruction code includes harvesting of the flap, microvascular transfer, closure of the donor site, and inset/shaping of the flap into a breast. The CPT code book specifically states that use of the operating microscope cannot be added.

It does not include repair of an incidentally found hernia, which may be coded additionally.

7

A 5-year-old boy is brought to the office because of a whistle deformity. History includes repair of a bilateral cleft lip at 6 months of age. On examination, the orbicularis oris is not in continuity across the lip. Dry, crusting mucosa on the vermillion of the whistle deformity and nasolabial fistulas are noted. A cleft lip revision is planned to repair the muscles, close the nasolabial fistulas, and correct the whistle deformity. Which of the following Current Procedural Terminology (CPT) codes is most appropriate for this procedure?
A) 40650 (Repair lip, full-thickness; vermillion only)
B) 40652 (Repair lip, up to half of vertical height)
C) 40654 (Repair lip, over one-half vertical height, or complex)
D) 40701 (Primary bilateral lip repair, one-stage procedure)
E) 40720 (Secondary lip repair, by recreation of the defect and reclosure)

E) 40720 (Secondary lip repair, by recreation of the defect and reclosure)

Since all components of the lip require revision, this is best achieved by recreation of the defect, and therefore the most appropriate code is 40720. Minor revisions of vermillion only or of half the lip would not address correction of all the components requiring reconstruction. Only recreation of the defect and repair will allow for closure of nasolabial fistulas, whistle deformity, and repair of the orbicularis oris across the lip.

8

A 53-year-old woman comes to the office for symmetry revision of a previous breast reconstruction that requires a Ryan flap. The area of advancement is 15 × 4 cm. Which of the following is the most appropriate Current Procedural Terminology (CPT) coding for this procedure?
A) 14001 (Advancement flap, 10 to 30 cm2)
B) 15734 (Muscle, myocutaneous or fasciocutaneous flap; trunk) and 14301 (advancement flap, 30 to 60 cm2)
C) 19380 (Revision of reconstructed breast)
D) 19380 (Revision of reconstructed breast) and 14001 (Advancement flap, 10 to 30 cm2)
E) 19380 (Revision of reconstructed breast) and 14301 (Advancement flap, 30 to 60 cm2)

E) 19380 (Revision of reconstructed breast) and 14301 (Advancement flap, 30 to 60 cm2)

A Ryan flap involves advancement of the lower thoracic skin and subcutaneous tissue in postmastectomy breast reconstruction. It is helpful for modest supplementation of prethoracic skin coverage and creation of a well-defined inframammary fold. The benefits of this maneuver include a good skin color match, ease of performance, and a scar that is confined to the inframammary fold area.

A Ryan flap is not a global component of any of the breast reconstruction codes. The advancement flap procedure is reported separately. The code selected is based upon the surface area of the flap: 14001 (advancement flap, 10 to 30 cm2) or 14301 (advancement flap, 30 to 60 cm2).

9

Which of the following is an example of proper Current Procedural Terminology (CPT) coding when submitting charges for procedures performed?
A ) Coding for debridement of a traumatic wound, as well as its complex closure
B ) Coding for hernia repair in a transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction due to use of mesh for abdominal wall repair and closure
C ) Coding for primary closure of an anterolateral thigh free flap donor site in a lower extremity reconstruction
D ) Coding for resection of skin cancer and coding for local small rotation flap to reconstruct
E ) Coding for skin grafting to a radial artery free flap donor site in a head and neck reconstruction

E ) Coding for skin grafting to a radial artery free flap donor site in a head and neck reconstruction

Proper coding and thorough familiarity with the descriptions of the Current Procedural Terminology (CPT) is essential to avoid mistakes or involvement in insurance/payer abuse or fraud litigation.

Based on the CPT manual, skin graft closure of a radial artery free flap donor site is a separate procedure and can be billed separately.

Billing for the complex closure of a traumatic wound includes the debridement of the wound before closure.

Abdominal wall repairs are included in transverse rectus abdominis musculocutaneous (TRAM) flap cases and should not be billed separately.

Anterolateral thigh free flap donor site closure is included in the initial charge for the free flap and should not be billed

10

A 34-year-old man comes to the office because of a 10-mm nevus on the right cheek. He is concerned because it bleeds every time he shaves. Excision of the nevus is planned. In addition to Current Procedural Terminology ICD-9-CM diagnosis code 216.3 (nevus), which of the following diagnosis codes is most appropriate to use when coding the lesion described?
A ) 173.30 (neoplasm skin, primary)
B ) 238.2 (neoplasm skin, uncertain behavior)
C ) 459.0 (bleeding)
D ) 782.9 (changing skin lesion)
E ) No additional code needed

C ) 459.0 (bleeding)

Documentation of "complicating pathology" is required in the medical record as well as the ICD-9-CM diagnosis codes for Medicare to cover the excisions of benign lesions. If a "complicating pathology" code is not included, the procedure is considered ?not covered? or "cosmetic" by Medicare. According to the Centers for Medicare & Medicaid Services, bleeding, intertrigo, pain, and pruritus are all considered complicating pathologies that justify Medicare payment. ICD-9-CM diagnosis code 782.9 constitutes a changing skin lesion or a growing skin lesion. This may also be a useful ICD-9-CM diagnosis code to support the excision of a nevus, but not specifically in the scenario described. Because there was no history of the lesion changing or growing, ICD-9-CM diagnosis code 782.9 would not be appropriate. The lesion described was repeatedly traumatized and bled; therefore, the complication code 459.0 would be most appropriate. ICD-9-CM diagnosis code codes 173.30, 198.2, and 238.2 imply a skin lesion which is malignant (173.30), metastatic (198.2), or of uncertain

11

A 73-year-old man with a history of squamous cell cancer of the mid portion of the lower lip undergoes resection and reconstruction with a Karapandzic technique. The flap measures 6 × 2 cm. Which of the following Current Procedural Terminology (CPT) codes is most appropriate for this procedure?
A ) 12052 (Repair intermediate, lip 5.1 to 7.5 cm)
B ) 13132 (Repair complex, lip 2.6 to 7.6 cm)
C ) 14041 (Adjacent tissue transfer, head neck 10.1 to 30 cm2)
D ) 15732 (Musculocutaneous flap)

D ) 15732 (Musculocutaneous flap)

The Karapandzic technique is an axial pattern musculocutaneous flap based on the facial artery/vein. The flap is dissected together with its nerve and blood supply and is used to transfer a compound flap of skin and muscle for function repair of lip defects. The intermediate repair code (12052) is used to describe a layered closure of one or more deeper layers of subcutaneous and superficial tissues but does not include muscle closure that is performed with a Karapandzic technique. The complex repair code (13132) is used to describe repairs of wounds requiring more than a layered closure. These wounds include, for example, extensive debridement of traumatic injuries, extensive undermining, and use of retention sutures. The adjacent tissue transfer codes (14041) are used to describe repairs using transfer of adjacent tissues or rotation flaps that are not based on an axial blood supply (eg, Z-plasty, V-Y advancement flaps,

12

A 60-year-old man with a benign, 4-cm tumor of the superficial parotid gland undergoes tumor resection with a 12-cm preauricular incision. Which of the following is the most appropriate Current Procedural Terminology (CPT) coding for the procedure?
Code Explanation
21013 Excision subfascial soft-tissue tumor of the face less than 5 cm
42420 Excision of parotid tumor or parotid gland total with dissection and preservation of the facial nerve
64716 Neuroplasty and/or transposition cranial nerve
14041 Adjacent tissue transfer or rearrangement cheek defect 10.1 to 30.0 sq cm2
12054 Repair intermediate wound of the face 7.6 to 12.5 cm
A ) 21013 alone
B ) 21013 and 64716
C ) 21013, 64716, and 12054
D ) 42420 alone
E ) 42420 and 64716

D ) 42420 alone

Code 42420 is the most appropriate code because it includes the tumor resection, dissection of the facial nerve, and wound closure all bundled. Code 21013 is inappropriate because there is a specific code for a parotid tumor. Code 64716 is inappropriate because that is included in the parotid resection codes. It would not include code 14041 because primary wound closure is included in the surgical package. Code 12054 should not be used because this surgical procedure always implies a layered closure.

13

When coding surgery for an orbital fracture, which of the following is considered a separate Current Procedural Terminology (CPT) code?
A ) Elevation of the fracture
B ) Exploration of the infraorbital nerve
C ) Fixation of the malar fracture
D ) Orbital floor exploration
E ) Release of entrapment of orbital contents

C ) Fixation of the malar fracture

Orbital fractures most commonly involve the orbital floor and are often isolated fractures, ie, not associated with other fractures, including those involving the tripod. Although the orbital floor is part of the orbit, a separate series of codes is used to describe procedures for fractures. Each of these codes is global and includes:

• Elevation of the fracture
• Exploration of the infraorbital nerve
• Orbital floor exploration
• Release of entrapment of orbital contents (inferior rectus muscle, orbital fat).

The CPT codes for fracture differ in their surgical approaches and in whether or not implants or bone grafts are used. A transantral (Caldwell-Luc) orbital floor fracture reduction is reported with code 21385. If the procedure is performed through a periorbital incision, 21386 is used. A combined approach (both periorbital and transantral) is described with code 21387. Code 21387 includes both approaches — each approach is not coded separately. If an implant is placed through a periorbital approach to reinforce the orbital floor, code 21390 is used. If a bone graft is placed, code 21395 is used; this includes harvesting of the bone graft.

There are instances where a facial injury results in a depressed malar fracture and an orbital fracture, both of which must be surgically treated. The elevation of a fracture is not considered part of the global malar fracture reduction codes, although some commercial software bundling packages used by third-party payers may incorrectly ?overbundle? these codes together. If, for example, an open reduction and internal fixation (ORIF) of a malar fracture is performed, and through the periorbital incision an orbital fracture is elevated with release of entrapped soft tissue, code as follows:

Code Description
21386 Elevation of orbital blowout fracture
21360-59-51 ORIF malar fracture
Common Codes for Orbital Floor Fractures

Code Description
21360 ORIF malar fracture
21365 ORIF malar fracture, "complicated" (comminuted, involving cranial nerve foramina), including multiple approaches, without bone grafting
21366 ORIF malar fracture, "complicated" (comminuted, involving cranial nerve foramina), including multiple approaches, with bone grafting (includes obtaining graft)
21385 Orbital blowout, Caldwell-Luc approach
21386 Orbital blowout, periorbital approach
21387 Orbital blowout, combined approach
21390 Orbital blowout, periorbital approach with alloplastic or other implant
21395 Orbital blowout, periorbital approach with bone graft (includes obtaining graft)
21401 Orbital fracture, non-blowout, closed reduction
21406 Orbital fracture, non-blowout, open reduction, without implant
21407 Orbital fracture, non-blowout, open reduction, with bone graft (includes obtaining graft)

14

A 43-year-old woman comes for a follow-up visit 1 week after undergoing right modified radical mastectomy for breast cancer and subsequent reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap. She says she is worried that she might not be able to afford additional follow-up visits should she be obligated to pay. Which of the following is the most likely duration of the global period for this patient?
A ) 1 Week
B ) 1 Month
C ) 3 Months
D ) 6 Months
E ) 1 Year

C ) 3 Months

A global period is a specific period of time (generally 90 days after a surgery) that the patient receives follow-up care and postoperative visits without billing the insurance company. Patients must wait until their global period is complete before proceeding with the next stage of breast reconstruction. Global periods are federally mandated and cannot be changed. The global period for skin lesion is 1 week.

15

A 46-year-old woman is referred for evaluation regarding neck rejuvenation. Physical examination shows a full neck with an indistinct mandibular border and an obtuse cervicomental angle. Which of the following is the most likely cause of this obtuse angle in this patient?
A ) Anteriorly displaced chin
B ) High position of the hyoid bone
C ) Increased preplatysmal fat
D ) Posteriorly displaced thyroid cartilage
E ) Ptosis of the submandibular gland

C ) Increased preplatysmal fat

Patient evaluation for neck rejuvenation should include assessment of skin laxity, degree of preplatysmal and subplatysmal fat, and position of the chin, hyoid bone, and thyroid cartilage. In addition, the presence of a malpositioned or ptotic submandibular gland should be noted. The ideal aesthetic neck has been described as having a cervicomental angle of 105 to 120 degrees, a distinct mandibular border with a subhyoid depression, a visible sternocleidomastoid muscle, and thyroid cartilage.

An obtuse cervicomental angle can result from loose, excess skin; low position of the hyoid bone; excess preplatysmal or subplatysmal fat; and a retrodisplaced or small chin.

Excess preplatysmal fat is the most common cause of an obtuse cervicomental angle. Removal of the preplatysmal fat is corrected through direct excision or liposuction. Often, removal of the subplatysmal fat may also be required to improve the overall contour of the neck.

Excess skin laxity of the neck contributes significantly to the overall shape of the neck, resulting in poor definition of the mandibular border, sternocleidomastoid muscle, and the thyroid cartilage.

Poor chin definition caused by lack of projection or size can also result in an obtuse cervicomental angle.

The position of the hyoid bone can influence the aesthetic contour of the neck. The normal position for the hyoid bone lies in line with the fourth cervical vertebra. In patients with an obtuse cervicomental angle, the hyoid bone is low, projecting inferior to the fourth cervical vertebra and creating a full, obtuse neck contour.

Position of the thyroid cartilage or ptosis of the submandibular gland does not influence the overall aesthetic contour of the neck.

16

A 65-year-old woman undergoes breast reconstruction with a free transverse rectus abdominis musculocutaneous (TRAM) flap. Zones I and II of the flap are used, and part of Zone III and all of Zone IV are excised. The cartilaginous portion of the third rib is removed to expose the internal mammary vessels. Microvascular anastomosis with the aid of a microscope is performed between the flap pedicle and the internal mammary vessels. Which of the following Current Procedural Terminology (CPT) codes is most appropriate in this scenario?
A) Breast reconstruction with free flap (19364) and excision of rib, partial (21600)
B) Breast reconstruction with free flap (19364) and microsurgical techniques, requiring the use of operating microscope (69990)
C) Breast reconstruction with free flap (19364); excision of rib, partial (21600); and debridement; skin and subcutaneous tissue (11042)
D) Breast reconstruction with free flap (19364) only
E) Breast reconstruction with TRAM flap, single pedicle, including closure at donor site; with microvascular anastomosis (supercharging) (19368)

D) Breast reconstruction with free flap (19364) only

The scenario describes a breast reconstruction using a free DIEP flap. According to Current Procedural Terminology (CPT), the correct code is 19364, which is ?breast reconstruction with free flap.? This code does not distinguish between the type of flap that is used, nor does it distinguish among free TRAM flaps, muscle-sparing TRAM flaps, DIEP flaps, superficial inferior epigastric artery (SIEA) flaps, and so on. Included in this code is the harvest of the flap, the insetting and shaping of the breast reconstruction, the microvascular anastomosis, the use of the operating room microscope, and the closure of the donor site.

The use of code 21600, partial rib resection, is also considered bundled within the code for breast reconstruction with a free flap (19364).

It is not appropriate to enter the code for using the operating room microscope (69990) because this part of the procedure is bundled within the code for breast reconstruction with a free flap (19364). Using codes that are bundled within another CPT code is referred to as ?unbundling? and is inappropriate.

The use of a debridement code (11042) would not be appropriate. For the purpose of breast reconstruction and shaping, trimming of the flap is part of the harvest and inset of the flap.

The code 19368 would not be appropriate because it describes a single pedicled TRAM flap that is supercharged. Supercharging typically involves an additional microvascular anastomosis between the deep inferior epigastric vessels and, usually, the thoracodorsal vessels to augment the flap’s blood supply.

17

A 68-year-old woman undergoes partial glossectomy, resection of the anterior floor of the mouth, and bilateral modified radical neck dissection to treat squamous cell carcinoma in the ventral tongue and anterior floor of the mouth. The resulting defect is reconstructed with a 5 × 6-cm radial forearm free flap. The free flap is anastomosed to the left facial artery and left internal jugular vein. The forearm donor site is reconstructed with a split-thickness skin graft from the thigh. In addition to Current Procedural Terminology (CPT) code 15758 (free fascial flap with microvascular anastomosis), which of the following is most appropriate?

A ) 13152: Complex repair mouth 2.6 €“7.5 cm

B ) 15100: Split thickness skin graft, arm; less than 100 cm2

C ) 35761: Exploration of vessels without repair

D ) 40840: Anterior vestibuloplasty

E ) 69990: Use of operating microscope

B ) 15100: Split thickness skin graft, arm; less than 100 cm2

Free flap procedure codes are global and include:

1. Elevation of the flap
2. Isolation of donor flap vessels used for microvascular anastomosis
3. Transfer of the flap to the recipient site
4. Isolation of the recipient vessels used for microvascular anastomosis
5. Microvascular anastomosis of one artery
6. Microvascular anastomosis of one or two veins
7. Inset of the flap in the recipient site
8. Primary closure of the donor site
If a free flap procedure involves more than one of the above global components, it is appropriate to report these as added elements, as they are considered over and above the usual free flap procedure. These can include:

1. Vein grafts
2. Neurorrhaphy
3. Nerve grafts
4. Skin grafts €“ donor site or recipient site
5. Closure of the donor site that is more extensive than primary closure
6. Wound preparation of the recipient site
Additionally, CPT 69990, use of the operating microscope, is also included with the free flap codes. It should not be coded separately.

18

A 62-year-old woman has biopsy-proven basal cell carcinoma of the left cheek. A 3-cm-diameter lesion is excised with a margin of normal tissue, leaving a circular defect measuring 4 cm in diameter. The surgical defect is reconstructed with a large cheek rotation flap measuring 25 cm2, which is inset in layers using deep sutures and cutaneous sutures. Which of the following is the most appropriate CPT code for the repair?

A ) 12052 €“ Layered closure of wound of face 2.6 cm to 5.0 cm

B ) 12056 €“ Layered closure of wound of face 20.1 cm to 30.0 cm

C ) 14040 €“ Adjacent tissue transfer cheek defect 10 cm2 or less

D ) 14041 €“ Adjacent tissue transfer cheek defect 10.1 cm2 to 20 cm2

E ) 14300 €“ Adjacent tissue transfer more than 30 cm2, any area

E ) 14300 €“ Adjacent tissue transfer more than 30 cm2, any area

An important clarification in the use of the adjacent tissue transfer codes (14XXX) appears in CPT 2004. The term €œdefect € is now clearly defined: €œFor purposes of code selection, the term €˜defect €™ includes the primary and secondary defects. The primary defect resulting from the excision and the secondary defect resulting from flap design to perform the reconstruction are measured together to determine the code. €

In the procedure described, the basal cell carcinoma was excised with a circular defect of 4 cm in diameter. A 4.0-cm diameter circular defect measures 13 cm 2 (area of the circle = pi r 2). The secondary defect with flap elevation measures 25 cm2. The code is selected by the total defect size, primary + secondary, which in this case equals 13 cm2 + 25 cm2 = 38 cm2. Therefore, code 14300 is appropriate.

The adjacent tissue transfer codes include the lesion excision, so do not report lesion excision in addition to the flap code 14300.

Reporting this code as a simple layered closure would be inappropriate as a cheek rotation (adjacent tissue transfer) is necessary to close the defect.

19

Which of the following is NOT included in the global carpal tunnel release Current Procedural Terminology (CPT) code 64721?

A ) Exploration of the motor branch

B ) Internal neurolysis

C ) 90 Days of uncomplicated postoperative care

D ) Release of distal forearm fascia (antebrachial fascia)

E ) Synovial biopsy or limited synovectomy

B ) Internal neurolysis

Internal neurolysis is not included in the global code 64721, although external neurolysis is. Internal neurolysis is reported as CPT code 64727. Release of distal forearm fascia (antebrachial fascia), exploration of the motor branch, synovial biopsy or limited synovectomy, and 90 days of uncomplicated postoperative care are included in the global CPT code 64721. Also included are €œincision, division of the palmar aponeurosis, division of the transverse carpal ligament, exploration of the carpal tunnel, release of the median nerve, exploration of the motor branch, release of the motor branch, epineurotomy, external neurolysis, closure of the operative wound, application of dressing, including wrist splint and anesthesia (local/wrist block) provided by the surgeon. €