I have a question about a re-elevation of a knee muscle flap. My doctor wants to bill CPT 15738-58 for muscle flap; lower extremity. The patient has undergone multiple reconstructive procedures of her right knee with prosthesis and prior flaps/muscle flaps were performed by my doctor. On this occasion, my doctor opens the knee for the orthopedic surgeon and then closes it back up for him. However, his documentation states...
"Along the inferior medial aspect was the medial gastrocnemius muscle flap. As we approached this area, I was able to idenfiy the Ethibond sutures. I took meticulous care to RE-ELEVATE this medial gastrocnemius muscle without damaging the muscle itself or the skin graft overlying it."......."I was able to advance the medial gastrocneius muscle flap such that we were able to have tendon-to-tendon coverage from the gastrocnemius muscle. This close was complted using 0 PDS suture."
Is this billable with CPT 15738? Insurance denied stating documentation does not support.
Thank you for your answer in advance.
~K
"Along the inferior medial aspect was the medial gastrocnemius muscle flap. As we approached this area, I was able to idenfiy the Ethibond sutures. I took meticulous care to RE-ELEVATE this medial gastrocnemius muscle without damaging the muscle itself or the skin graft overlying it."......."I was able to advance the medial gastrocneius muscle flap such that we were able to have tendon-to-tendon coverage from the gastrocnemius muscle. This close was complted using 0 PDS suture."
Is this billable with CPT 15738? Insurance denied stating documentation does not support.
Thank you for your answer in advance.
~K