General Surgery Coding Alert

Distance is key for 15570-15650.

Missing just one intermediate step when your surgeon performs a pedicle flap procedure could cost your practice $365. But charging for that same intermediate step in some circumstances could lead to fraud charges.

Let our experts guide you, step by step, to the correct pedicle flap code -- every code, every time.

Step 1: Distinguish Pedicle Flaps

A pedicle flap is a type of nonadjacent tissue transfer that initially remains attached to the donor-site blood supply. The surgeon cuts a "stalk," or pedicle of tissue, that includes a flap the proper size and shape to repair a defect that is not contiguous with the donor site. The surgeon then maneuvers the flap to the repair site, still attached by the pedicle to the donor site, and later cuts the pedicle free.

Watch for: You might also see this technique called "attached flap" or "tubed pedicle," which refers to a sub-type that involves stitching together the long sides of the pedicle to form a tube.

The codes that describe pedicle flaps can refer to transfers of skin and/or deep tissues, according to Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program.

Step 2: Use One 'Formation' Code

When the surgeon forms the pedicle flap, you should select the appropriate code from the following list:

15570 -- Formation of direct or tubed pedicle, with or without transfer; trunk

15572 -- ... scalp, arms, or legs

15574 -- ... forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet

15576 -- ... eyelids, nose, ears, lips, or intraoral.

Transfer included: Codes 15570-15576 include transfer to the recipient site -- if the surgeon performs the transfer right away,that is. "The code descriptor states 'with or without transfer,'so you should use the same code whether or not the surgeon immediately transfers the flap," Bucknam explains.

Each of these codes refers to a specific body site, but because a pedicle flap involves two sites -- donor and recipient -- coders often find the choice daunting. The choice is even more confusing because the correct code varies depending on the circumstances.

Solution: Choose the code based on the following criteria:

For immediate transfer cases, select one code from the range 15570-15576 based on the recipient site

For delayed transfer cases, select the code from the range 15570-15576 based on the donor site.

Don't lose extra pay: Your surgeon might earn extra pay in the following circumstances:

Pedicle flap formation codes don't include lesion excision,unlike adjacent tissue transfer codes (14000-14302, Adjacent tissue transfer or rearrangement ...). You should separately report an excision using a code from the range 11600-11646 (Excision, malignant lesion including margins ...) if the surgeon performs the work prior to forming the pedicle flap.

"Although 15570-15576 include primary closure,you can separately code the donor site repair if it requires procedures such as skin graft or local flaps," Bucknam says.

Step 3: List Intermediate Transfer Only With Delay

If the surgeon delays the pedicle flap transfer, you'll need to report an extra step. "Use 15650 (Transfer, intermediate, of any pedicle flap [e.g., abdomen to wrist, walking tube], any location) when the surgeon transfers the pedicle flap to the recipient site at an operative session separate from the earlier pedicle formation surgery," Bucknam says.

Get this: Because surgeons receive $364.82 (based on the Medicare physician fee schedule national facility amount using conversion factor 36.0846) for the intermediate transfer, you can't afford to miss this step.

Avoid fraud: On the other hand, if the surgeon transfers the flap during the same surgical session as he forms the flap, you shouldn't report 15650. "Remember that codes 15570-15576 include an immediate transfer," Bucknam warns.

If the surgeon must "walk" the flap from one site to a distant site through multiple transfers, you should list 15650 for each intermediate transfer.

Step 4: Report Division and Inset

After enough time has passed for vascular development at the recipient site, the surgeon cuts the pedicle near the repair site and shapes and sutures the final graft. The surgeon may also return a portion of the pedicle to its original position, or in some way complete closure of the pedicle defect. You should report this step using the appropriate code from this list:

15600 --  Delay of flap or sectioning of flap (division and inset); at trunk

15610 --  ... at scalp, arms, or legs

15620 -- ... at forehead, cheeks, chin, neck, axillae, genitalia, hands or feet

15630 -- ...  at eyelids, nose, ears, or lips.

Example: The surgeon prepares a pedicle flap from the cheek and transfers it to a defect site on the nose, which you should report as 15574. One week later, the surgeon completes the transfer, performing the flap division and inset, which you should code as 15630.

Watch for modifier: You will need to use modifier 58 (Staged or related procedure by the same physician during the postoperative period) with 15630 in this example. "Because the sectioning of the pedicle flap falls within the pedicle formation[15574] global period, you need a modifier to tell the insurer that the service is a staged procedure and therefore payable," explains Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J.