tci General Surgery Coding Alert - 2007 Issue 9

Reader Question ~ Multiple Flaps Could Mean Appending 59

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)...

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