Can I bill for flaps???


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I have a Doc that performed an excision of a lesion on the lip and noted in his report "Flaps were created." Can I bill procedure code 14060? I have included the "procedure" portion of the operative report. I am using proc code 11442 for the primary procedure since the path report states "1.3x0.7cm lip lesion".

"This 69-year-old female has a vascular ectatic lesion of the right upper lip. It is located in the vermilion border. It measures 1 cm x 1 cm. At operation, it was widely excision without incident.

The patient was taken to the operating room and placed on the operating table in the supine position. After an adequate level of IV sedation was obtained, the right upper lip was prepped and draped in the usual sterile fashion with Betadine. 1% lidocaine with 0.25% Marcaine were injected for local anesthesia. A vertical incision was made and the entire vascular ectatic lesion excised with an ellipse of overlying mucosa. The incision did not go beyond the squamous junction and was contained within the vermilion border exclusively. The lesion was completely excised. Bleeding was controlled with the Bovie electrocautery unit. The lesion was passed off as an operative specimen. Flaps were created. The skin edges were then reapproximated using interrupted simple sutures of 5-0 chromic. Antibiotic ointment was applied. All sponge, instrument and needle counts were correct x2 at the conclusion of the case. The patient tolerated the procedure well and was taken to the recovery room in stable condition."

Thank you in advance for your help!
Flaps include lesion removal

Please read the guidelines for adjacent tissue transfer (i.e. flaps). If you documentation included sufficient detail (it does NOT, by the way) to use the 14060 code, you would NOT code the lesion excision separately.

As documented, I would code only for the lesion removal.

Hope that helps.

F Tessa Bartels, CPC, CEMC