March 16, 2023

Question:
How should my physician document an adjacent tissue transfer? My physician documents the total in sq cm for the entire repair.

Answer:
The primary and secondary defect dimensions are required. The primary defect is the excision site and the secondary defect results from the flap design to perform the reconstruction. So documentation in the operative report must include:

1. Primary defect-sq cm
2. Secondary defect sq cm
3. Primary defect sq + secondary defect sq cm=CPT code

*This response is based on the best information available as of 03/16/23.