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Free flaps

Denise Posted Wed 21st of September, 2016 16:51:09 PM
My docs do a lot of free flaps and frequently they have to repair the anastomosis. I am not sure what to code when this comes up. Below is a sample op report. Preop Dx: S/p free flap with wound vac and xenograft Postop Dx: Same, venous compromise Procedure: Preparation of wound bed 420cm2, placement of integra 420cm2 Revision of microvascular anastomosis (vein) Placement of wound vacuum >50cm2 Anesthesia: GETA EBL: min____ Complications: Venous compromise - revised with wound exploration and microvascular anastomosis revision Findings: As above Drains: vac   Brief Clinical History ____is a pleasant ___ male with a history of massive desmoid tumor resection s/p free latissimus who is not POD 5 after the flap. He has a history of hypercoagulability and has been on heparin. He presents for wound vac change and evaluation of the xenograft.   The risks of surgery include but are not limited to bleeding, pain, infection, damage to surrounding tissue, scarring, asymmetry, disability, wound healing problems, loss of flap, and need for further intervention.   Operative Report The patient was brought into the operating room and placed in the left side up position. All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia. All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision. A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.   Prior to surgery a timeout was performed with the anesthesia team regarding the importance of maintaining his blood pressure and avoiding pressors.   The was clean and the xenograft was removed - there was an area of exposed posterior rib that would require integra. Consequently i decided to remove the xenograft and to place integra during this case. The wound was irrigated copiously with abx saline and the flap was pink and viable. A currette was used to remove any fibrinous debris. The wound was 420cm2 and I stapled meshed integra onto the wound. At this time, I placed the wound vacuum on and as the adhesive was being applied, his venous coupler signal went down. His flap had been sensitive to the position of his arm and this was manipulated to no effect.   The axilla and back incisions were opened and the pedicle and vein graft evaluated. There was no clot in the graft or at the axillary anastomosis. There appeared to be venous congestion at the pedicle of the latissimus and the coupler was taken down. There was brisk flow of blood and the flap was flushed with heparinized saline. Thereafter, I revised the vein using a 2.5mm flow coupler. His signal returned with his arm in the similar position. The wound was irrigated and the skin closed with staples. The wound vacuum was placed to suction with no change in the doppler. The patient was taken back to the ICU with a good venous signal.      
SuperCoder Answered Thu 22nd of September, 2016 03:22:10 AM

AAE does not provide coding for operative reports and chart notes.

SuperCoder offers SuperCoding on Demand (SOD) ( for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail for more information.

Denise Posted Thu 22nd of September, 2016 13:20:54 PM
So since this was not answered am I being charged for this. If not how can I ask another question?
SuperCoder Answered Fri 23rd of September, 2016 03:48:43 AM

Hi, You will not be charged for this question. You can ask another question here, in the same thread. Please post your question below. 

In context to operative report, please contact (866)228-9252.

You can also e-mail at

You will be asked to send us the operative report.

Please let me know in case of any further help required.

Denise Posted Fri 23rd of September, 2016 17:14:53 PM
My plastics surgeon do a lot of free flaps for wound closures. Occasionally they have to repair the anastomosis. They often repair with a vein graft but other times they just state they did a resection and repaired with another anastomosis. I am lost on a code for the repair of vein with just a resection?
SuperCoder Answered Mon 26th of September, 2016 03:06:30 AM

There is no specific code for revision of pedicle and vein graft through flow coupler. The nearest code that can be related to is CPT code 35876 with 52 modifier appended for reduced services. Revision of arterial or venous graft was performed, however, thrombectomy was not performed.

The other option is to bill unlisted code 37799 (Unlisted procedure, vascular surgery). When submitting an unlisted-procedure code, your documentation should also include an explanatory cover letter. An insurer will decide to pay an unlisted-procedure claim by comparing your procedure description to a similar, listed procedure with an established reimbursement value.




Denise Posted Mon 26th of September, 2016 12:05:29 PM
Thank you. How about if they use TPA?
SuperCoder Answered Tue 27th of September, 2016 03:06:43 AM

Tissue plasminogen activator (TPA) is administered through IV infusion. CPT code 75896 (Transcatheter therapy, infusion, other than for thrombolysis, radiological supervision and interpretation) was being used till Jan 1, 2016. The corresponding procedure reportable with this code was also deleted, 37202- Transcatheter therapy, infusion other than for thrombolysis, any type (egg, spasmolytic, vasoconstrictive). There is no CPT code at present that defines this procedure. Please bill an unlisted code. When submitting an unlisted-procedure code, your documentation should also include an explanatory cover letter. An insurer will decide to pay an unlisted-procedure claim by comparing your procedure description to a similar, listed procedure with an established reimbursement value.

Please find below the link from TCI coding conference for more understanding:


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