Full Thickness Skin Graft Closure

dyoungberg

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Dr performed the following on a patient:

PREOP DIAGNOSIS: BCC RIGHT SIDE OF NOSE
POSTOP DIAGNOSIS: SAME

PROCEDURE: RESECTION OF BCC, RIGHT SIDE OF NOSE, WITH FULL THICKNESS SKIN GRAFT CLOSURE AND ROTATIONAL ADVANCEMENT FLAP CLOSURE OF DONOR SITE

COMPLICATIONS: NONE

OPERATIVE FINDINGS: There was a tattooed 1.2 cm in diameter shallow erythematous scar overlying the alar crease about midway between the dorsum and the lateral alar margin.

PROCEDURE: Under IV sedation, the patient was prepped and draped in a sterile manner in order to give good exposure to the head and neck. The area surrounding the lesion and the left lip-cheek crease area were infiltrated with a total of 10 cc Lidocaine 1% w/epinephrine 1:100,000. A fusiform 4.0 x 1.4 cm segment of full thickness skin was excised, encompassing the lesion. The adjacent skin was undermined. A similar sized segment of skin from the lip-cheek crease on the ipsilateral side was excised, tailored to size, and inserted into the defect. It was sutured in place with 5-0 Rapide skin sutures and a bolster of Adaptic, followed by a cotton ball moistened with Betadine using 5-0 Prolene stay sutures. The donor site was closed in a rotational advancement flap fashion. The adjacent skin was undermined, rotated, and advanced to fill the defect. The subcutaneous tissue was closed with 4-0 Monocryl and the skin with 5-0 Rapide. Polysporin ointment was applied. The patient awakened and returned to the recovery room in good condition. There were no complications.

Frozen section histoanalysis revealed margins free of tumor.


When submitting this to Medicare I coded this as 11646 for the lesion excision, 15260 for the repair and 14040 for rotational flap repair of the donor site. Medicare paid 15260 & 14040 but denied 11646 as procedure not paid separately. Was I wrong in coding 11646? Any thoughts or advice on this?

Thanks very much!

Debbie Youngberg
CPC-A
 

dyoungberg

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Full Thickness Skin Graft

Dee,

This went to Medicare with no modifiers. Upon looking at the op note again I think I should have added a 59 to 14040.

Debbie
 

dyoungberg

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Full thickness skin graft closure

14040 wasn't really an excision of a lesion. The defect was created when a graft was taken to repair the nose lesion excision. The doctor then did a rotational advancement flap repair of the donor site.
 

dyoungberg

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11646 was the excision of nose lesion, 15260 was the skin graft to close the lesion excision. Then the Dr did rotational flap repair of the donor site instead of direct closure. I don't understand why 11646 & 15260 can't be billed together and paid. 14040 is a separate procedure entirely. Am I not thinking about this correctly?
 
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