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division and insert of intraoral flap

Deaconess Posted Wed 21st of December, 2016 13:45:59 PM
the range of codes to select are 15600-15630, but none refer to intraoral (surgery was performed on the floor of the mouth). Would we use 15630, with a modifier of some sort? or are we required to use an unlisted code? 15600: delay of flap or sectioning of flap (division and insert), at trunk 15610: at scalp, arms, or legs 15620: at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet 15630: at eyelids, nose, ears, or lips
SuperCoder Answered Thu 22nd of December, 2016 01:55:59 AM

All of these CPT codes are inappropriate for the procedure performed. There would be an appropriate code to match the procedure.

Kindly provide the detailed procedure.

Deaconess Posted Thu 22nd of December, 2016 11:26:16 AM
would it be code 14040? Procedure: Stage II division and inset left medial labial fold flap reconstruction anterior floor of mouth. Patient was taken to the operating room, placed in supine position, underwent general endotracheal intubation anesthesia. To begin with, an elliptical excision was made of the base of the pedicle of the flap at the inferior most aspect of the melolabial fold. After this was circumferentially incised through skin, blunt dissection performed to avoid injury to any neurovascular structures. After this was dissected externally, attention was placed to the oral cavity. An elliptical excision was made through the area of mucosalized healing to the flap pedicle. The flap could then be pulled through, gently dissected, and transected with good mucosal and cutaneous incisions. The intraoral component was closed using a 3-0 Vicryl in a deep inverted interrupted subcuticular fashion. The flap pedicle then was addressed, and with the tongue under gentle tension the length of the pedicle was divided so as to be able to inset. It was partially defatted at the base of the reconstruction. This was then closed using a 3*0 Vicryl in a simple interrupted fashion. The nasal cavity, oral cavity, and pharynx were suctioned free of all blood and debris. On palpation, the inset site was clean and dry. The patient tolerated this well and was allowed to emerge from anesthesia.
SuperCoder Answered Fri 23rd of December, 2016 07:49:09 AM

Yes, CPT 14040 is appropriate code.

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