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axillary hidradenitis and raised flaps for closure

Tanesha Posted Wed 10th of July, 2019 17:27:04 PM
Would you only code 11451-50 or the adjacent tissue codes (14301, 14302 x 3)? Is the "raise of subq flaps" enough to code adjacent transfer as add'l incisions are not mentioned. EXCERPT: Using a #15 blade scalpel, a 10 x 10 cm ellipse of diseased specimen was excised from above the right axillary fat pad with a combination of sharp and blunt dissection. Attention was turned to the left side. 12 x 10 cm ellipse specimen was removed in nearly identical fashion.  Defects measured ~10 x 15 cm. Posterior and anterior subcutaneous flaps were raised from the wound bed to create laxity for wound closure on both sides. The wounds were closed in multiple layers with interrupted 3-0 vicryl sutures, starting by re-approximation of subcutaneous flap edges, followed by dermis. Skin was closed with running 3-0 monocryl suture. 15F CWV drain was placed deep to the created flaps in attempt to reduce risk of seroma formation.
SuperCoder Answered Thu 11th of July, 2019 05:32:45 AM

AAE does not provide coding/reviewing for operative reports and chart notes. SuperCoder offers SuperCoding on Demand (SOD) ( for coding/reviewing of an operative report or chart note and you can contact (866)228-9252 or e-mail for more information.


On the question of coding 11451 and 14301 together:

In this procedure 11451, the provider removes skin and subcutaneous tissue in the axillary region to treat hidradenitis. The provider incises the vascular inner layer of skin, dissecting down to and underneath the apocrine (sweat) glands to the level of diseased tissue. The provider then excises the entire diseased skin and subcutaneous fatty tissues overlying and underneath the apocrine (sweat) glands and down to the muscular fascia so that any abnormal opening area is exposed and removed. The provider then performs a complex, layered repair of the wound with heavy reinforcing sutures; sometimes a graft or flap may be needed for closure of the surgical wound. When a skin graft or flap is used for closure, report the additional code.

On the other hand, in Adjacent Tissue Transfer (ATT) procedure, the provider clearly demarcates the exact area of defect on the skin. He performs adjacent tissue transfers to cover any area by relocating a flap of adjacent normal, healthy tissue into a damaged area. The provider carries out the excision of the area he has marked. He raises a flap from the adjacent healthy tissue. Then the provider fixes this flap into the area of primary or secondary integumentary defect. Whereas, in your case, subcutaneous flaps were raised from the wound bed to create laxity for wound closure, this is not considered as ATT, so it is suggested not to code for 14301 and 14302.

Modifier 50 is good to go with 11451. Also, if you feel that there is extra work has been performed and documentation supports, then append modifier 22 (Increased Procedural Services) with the procedure (11451).

In order to append modifier 22 to a surgical procedure, check that the physician documented the reason(s) why the work he performed was more than he typically performs, and the documentation should include any or all of the following:

  • Increased intensity
  • Additional time
  • Technical difficulty
  • Severe patient condition, which causes the surgery to be difficult, dangerous to the patient, and requires additional physical and mental effort from the physician

An unusual procedure is not when the physician took only a few extra minutes on the patient’s case or when the physician documents that the procedure was only slightly more difficult. There is an average range of difficulty for every procedure. A procedure could be slightly more difficult and still meet the definition of the procedure and not warrant appending modifier 22.

Hope this help!

Tanesha Posted Thu 11th of July, 2019 08:40:40 AM
Thank you. My eyes saw the raised flaps and thought automatically the ATT, but I see your point as the flaps were raised from the wound bed, therefore, ATT wouldn't apply.
SuperCoder Answered Fri 12th of July, 2019 05:11:11 AM

Hi Tanesha,

Yes, you are right. As suggested earlier, check the complete documentation and select the procedure accordingly. Also, check the modifier 22 for better billing.

Wish you the best reimbursement!

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