Wiki COMPLEX REPAIR DOCUMENTATION

[maryb@practiceworksmd]

UHC is denying my Surgical Oncologist's complex repair of radical resection, "...does not meet criteria...a more appropriate CPT code ...should b used". This is his documentation. "Closure is made as a complex wound repair of the right upper back wound. It measures 14.2 cm prior to incision. Intermediate closure is not possible. Flaps were developed with extensive undermining under each edge at the level of muscular fascia for a distance of 2.5 cm lateral and 2.5 cm medial perpendicular to the line of closure. This extensive undermining measures 5.0 and is greater than the maximum width of the defect 4.5 cm as measured perpendicular to the closure line along both edges of the defect. There is exposure of spinous raphae perforating vessels and muscle. Meticulous hemostatis is made. The area mobilized is 126 cm2 (9.0 x 14.0). Closure is made with rotation and advancement as a double s-plasty. A three layered closure is made using buried 2-0 Vicryl for the deep subcutaneous fascia numbering 10 sutures, buried 3-0 Vicryl for the subdermal fat layer numbering 16 sutures and running 4-0 Monocryl for the skin." Billed 13101 and 13102. I don't think adjacent tissue transfer or advancement flap codes would be appropriate. Any opinion would be greatly appreciated!

 

[HReed]

Closure is made with rotation and advancement as a double s-plasty. -- I am unclear how that statement would not be considered as an adjacent tissue transfer or advancement flap. Also note that "Flaps were developed..." The description provided leads to 14000 and 14001 in my opinion. Complex closure is included in the advancement flap. Your description does not indicate if an excision of some type occurred at the same operative session, performed by the same doctor, but a complex close is usually included with radical resections, and the tissue rearrangements/advancement flaps are not.