Editor's Note: This article by Paul Cadorette, director of education for mdStrategies, originally appeared in The Coding Advocate, mdStrategies free monthly newsletter. Sign-up to receive this newsletter by clicking here.
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There are many challenges that a coder faces when reporting services for lesion excision, adjacent tissue transfer or graft procedures. The first of which is having the necessary documentation such as the correct size of the lesion, flap or graft being documented in the operative report. As simple as this sounds, many physicians do not include this information in their dictation.
Another area of concern is reporting CPT codes for services that were not performed. Take for instance an op note where the physician indicates an adjacent tissue transfer by use of "advancement flaps". The coder has to be aware of this terminology because when the physician undermines the adjacent tissue and advances flaps of skin towards each other it would not constitute an adjacent tissue transfer procedure. There is REVISED text in the 2010 CPT manual, located under the title of "Adjacent Tissue Transfer or Rearrangement," that reads;
"Undermining alone of adjacent tissues to achieve closure, without additional incisions does not constitute adjacent tissue transfer, see complex repair codes 13100-13160".
So as a coder, when you see advancement flap closure you need to determine whether the adjacent tissue was merely undermined (complex closure) or were additional incisions made to develop pedicle skin flap(s) which were then advanced into the defect (adjacent tissue transfer) for closure.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.