Results 1 to 5 of 5

would you code a 14041 on this scenario?

  1. #1
    Default would you code a 14041 on this scenario?
    Medical Coding Books

    PROCEDURE: Reconstruction of left upper forehead defect with almost total forehead and scalp advancement flap with galeal scoring.

    CLINICAL HISTORY: This 76-year-old male presented with a rather large 48x29 mm defect, oval in shape, on the left superior forehead and left frontal scalp. Previous scars were noted on the mid vertex scalp, as well as on the left forehead, precluding mobile skin.

    OPERATIVE PROCEDURE & FINDINGS: After satisfactory LMA, the areas were infiltrated with 1% Xylocaine with epinephrine and a supraorbital nerve block accomplished. The periosteum was intact beneath the wound, which was oval in shape. Considerable rigidity was noted in the scalp tissues, as well as the left forehead because of previous surgery and scars. A skin graft was considered, but because of the aesthetic defect, a flap reconstruction was elected. Accordingly, an almost total scalp dissection was accomplished above the periosteum, beneath the galea, over to the right ear, and almost back to the occiput. The galea was then scored. Using serial tissue expansion, the mobility was gained of approximately 1.5 cm

    In a similar fashion, the entire mid to left forehead, down to the zygoma, was dissected beneath the galea, and again galeal scoring accomplished. The wound edges were advanced and secured with 3-0 Monocryl under considerable tension in the galea. Burrow's triangles were then resected medially and posteriorly to create an S-shaped type of incision measuring 8 cm in length. Finally, the skin was approximated with 3-0 nylon. A small gap was left in the mid portion to avoid excessive tension. This produced an aesthetic result to prevent distortion of the landmarks and depression. Antibiotic ointment and sterile dressings were applied.


  2. #2
    yes that looks correct...the only thing that causes me to contemplate another code is the

    "Using serial tissue expansion, the mobility was gained of approximately 1.5 cm"

    but there really isnt enough documentation to support it..

    What do others think?

  3. #3
    Albany, New York
    I agree.......
    Karen Maloney, CPC
    Data Quality Specialist

  4. #4
    Thanks a lot! I agree with both

  5. #5
    yes, agree...14041.

Similar Threads

  1. Code the scenario: Capture the primary diagnosis code only
    By Ally718 in forum Diagnosis Coding
    Replies: 1
    Last Post: 09-22-2015, 08:41 AM
  2. E/M Code Scenario
    By Partha in forum E/M
    Replies: 2
    Last Post: 02-23-2010, 11:27 AM
  3. How would you code scenario?
    By Partha in forum E/M
    Replies: 3
    Last Post: 11-23-2009, 06:35 AM
  4. Code this scenario please:
    By Partha in forum E/M
    Replies: 6
    Last Post: 07-23-2009, 11:20 AM
  5. how would you code this scenario????
    By elenax in forum Plastic Surgery
    Replies: 2
    Last Post: 09-15-2008, 04:04 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.