As part of a surgery to correct a ruptured breast implant, the plastic surgeon performed what she says were 2 separate distinct procedrues to reconstruct an axillary scar contrature -each measuring 4.5 cm per Z-plasty. She is wanting to bill 14040 twice and I am questioning if this would be billed per Z-plasty or would it be combined and be billed on the total cm as in other wound closures?

The following is a condensed version of the OP note with just the Z-plasty portion:

4. Excision of a scar in the left axilla, 5 cm.
5. Tissue rearrangement two separate distinct procedures to reconstruct the left axillary scar contracture. Each of the two Z-plasties had three limbs each measuring 1.5cm (4.5cm per Zplasty).

SPECIMEN: Left breast implant material and the axillary dissection scar contracture.

...Attention was then turned to the left axilla. The existing scar band had been marked in the preoperative holding area. This was injected with local anesthesia. A pointed ellipse was designed to remove the scar band. This was then sharply created using a 15 blade and then the ellipse was closed with deep dermal suture. Then two separate Z-plasties were designed in order to break up the scar band. The length of each limb was 15 mm. The closure of the Z-plasties was performed in layers with an interrupted deep dermal 4-0 PDS layer followed by a running 4-0 Monocryl subcuticular closure of the entire axillary incision which measured 11 cm. The incision was then coated with Dermabond. Any excised tissue was sent to pathology as specimens.

If someone could look at this documentation and give me their opinion on whether there is enough documentation to support two separate Z-plasties or if it should be only one based on combined totals (which would be 9cm I assume) I would greatly appreciate it!