Perforator flap reporting may prove complicated
Reporting perforator flaps can be a challenge, as they comprise a vast spectrum of procedures, which are performed throughout all anatomic areas. This month's column will address the coding of perforator flaps.
The use of perforator flaps requires an understanding of vascular anatomy, not only of the perforator vessels themselves, but also of the angiosomes supplied by the perforating vessels. Just as the vascular anatomy and extent of muscle and fascial flaps have been defined over the years, the anatomy and angiosomes of perforator vessels have also been delineated.
Axial pattern
Consider a flap designed to include a perforating vessel in which the vascular pedicle is dissected for incorporation in the flap. This is an exacting dissection with potential for vascular compromise and flap loss. The time, effort, and knowledge necessary to execute a flap such as this is comparable to that for muscle or fascial flaps. In this case, use the 15732-15738 series to report the complexity of flap dissection.
Consider a thoracodorsal artery perforator flap. The artery is identified by doppler, and a skin paddle is fashioned and elevated. The thoracodorsal artery perforator and its accompanying vein are dissected from the muscle, then followed proximally to create a vascular pedicle. The flap is transposed as an island flap. This procedure is reported with code 15734.
If, on the other hand, a flap is designed over the angiosome of the thoracodorsal artery perforator, then elevated and transposed without actually dissecting the vessels, the surgical procedure is more akin to an adjacent tissue transfer. Report 14000, 14001 or 14301, based upon the area of the defect.
Random pattern
If a skin flap is designed to include cutaneous perforators, but the perforators are not dissected, this is a random pattern flap, and is reported with the adjacent tissue transfer codes, 14XXX. For example, a 10-by-5-cm Keystone flap of the thigh is designed to include cutaneous perforators. The flap is transposed and the donor defect is closed in V-Y fashion. This procedure is reported with code 14301.
What about perforator free flaps?
Free flaps based on cutaneous perforators, of course, require dissection of axial pattern vessels prior to transfer. Use code 15757 if the free flap is a skin flap; use code 15738 if a free fascial flap is transferred.
Free flap breast reconstructions are all reported with code 19364, whether the flap is a muscle flap, a fasciocutaneous flap or a perforator flap. There is not a separate code for perforator flap breast reconstructions. Thus a DIEP flap for breast reconstruction is reported with code 19364.
Summary
• If a perforator flap is fashioned and the perforator vessels are dissected out, this is a cutaneous or fascial axial pattern flap. Report this with the 15732-15738 series.
• If a flap is designed to include perforating vessels, but the perforators are not dissected, report with the adjacent tissue transfer series, 14XXX.
• Free flaps based on perforator vessels are reported with the free flap codes. Free cutaneous flaps are coded 15757. Free fascial flaps are coded 15738. Free flap breast reconstructions are coded 19364.
- Dr. Janevicius is the Society's representative to the AMA CPT Advisory Committee.
Code of the Month
A crush avulsion injury of the proximal ulnar palm results in a 2-by-2-cm ragged defect. The wound is excised and the defect closed with a distal ulnar artery perforator flap. A skin island is created after the artery is identified and dissected to the flexor carpi ulnaris tendon, and the flap is rotated 180 degrees to fill the defect.
Procedures
15736 Distal ulnar artery perforator flap
15004-51 Wound preparation
• The distal ulnar artery cutaneous perforator is identified and dissected, which creates an axial pattern island flap. This is reported with code 15736.
• Wound preparation (i.e., wound excision) is not included in code 15736 and is separately reported with code 15004.
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