Documentation and reporting requirements for adjacent tissue transfer or rearrangement

By Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, Senior Manager, Coding and Reimbursement, June 1, 2025

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Adjacent tissue transfer (ATT) or rearrangement procedures are vital in reconstructive surgery, particularly in dermatology, plastic surgery, and wound management. Proper documentation and coding are essential to ensure accurate reimbursement and compliance with payer policies, including Medicare and commercial insurers.

This article outlines the key documentation and reporting requirements for ATT or rearrangement procedures and provides some coding examples to clarify proper usage.

The adjacent tissue transfers or rearrangement, when performed, is reported with CPT^® code 14000-14350. The procedure is used to attain closure of primary or secondary integumentary defects by relocating a flap of adjacent normal, healthy tissue into a defect, including procedures such as Z-plasty, W-plasty, and V-Y plasty. If a lesion is excised and an adjacent tissue transfer or rearrangement is performed at the same site, the excision of the lesion is not reported separately.

The CPT guidelines for this series of codes include excision (including lesion) and/or repair by adjacent tissue transfer or rearrangement. When applied to the repair of lacerations, the procedure must be purposely performed by the surgeon to accomplish the repair. The guidelines further state that when direct closure or rearrangement of traumatic wounds incidentally results in configurations such as Z-plasty or V-Y plasty, these codes should not be reported.

• Both Medicare and CPT state that undermining alone of adjacent tissues to achieve closure, without additional incisions, does not constitute adjacent tissue transfer, BUT may constitute complex repair.

Understanding ATT or rearrangement

ATT or rearrangement involves the movement of skin and underlying tissues from a donor site to an adjacent recipient site to close a defect. These techniques include flaps such as advancement, rotation, transposition, and Z-plasty. The primary purpose of these procedures is to achieve wound closure while maintaining function and aesthetic integrity. The recipient site may be a laceration or a defect created by the removal of a lesion.

To perform adjacent tissue transfer (e.g., rotation flaps, advancement flaps, and double pedicle flaps), a tissue flap is created by surgically freeing the skin and underlying subcutaneous tissue and/or fascia. The base of the tissue flap remains connected to one or more borders of the donor site, thus maintaining the blood supply to the surgically created flap. Once the flap has been freed from the donor site, it is moved to cover the site of the defect, where it is sutured into place.

Transfer of the tissue flap may create an exposed area, or secondary defect, at the donor site, which may be closed by primary suturing of the wound edges. In some cases, however, a separate graft or flap may be required to close the tissue flap donor site. When another graft or flap is required for closure of the donor site, this is considered an additional procedure and should be reported with a separate CPT code.

Key documentation requirements

To support reporting for ATT and tissue rearrangement procedures, proper documentation must include:

• Indication for the procedure that clearly states the medical necessity, such as wound closure after skin cancer excision or trauma

• Anatomic site of transfer or rearrangement closure that specifically notates the location and area of the raised flap, plus that of the surgical defect (record the sum)

• Preoperative diagnosis that provides the ICD-10-CM code to its highest specificity that corresponds to the underlying condition necessitating the procedure

• Operative details that describe the specific flap type used, defect size, donor site location, and closure technique

• Verifiable defect measurement that clearly documents the primary and secondary defect and flap sizes in square centimeters

  • The total size of adjacent tissue repair is determined by adding the area of the defect to the area of the flap (e.g., triangular flap, quadrangular flap, etc.)

• Surgical technique describing the tissue mobilization and closure complexity by specifying how the tissue was mobilized and whether a secondary defect required additional closure

  • An example of payer-preferred wording could state:

    • A flap was raised and transposed (carried over) to cover the surgical defect

    • Adjacent tissue was incised and carried over to close the defect in the following manner

    • The postoperative care plan outlining wound care instructions, follow-up visits, and potential complications

Additional information to support a detailed documented medical record can include:

• Extent of undermining necessary to facilitate flap or rearrangement of tissue

• Type and volume of anesthesia, if performed

• Type of hemostatic techniques used (chemical, electrodesiccation, electrocautery, etc.)

• Estimated blood loss

• Post-closure measurement of defect

• Skin graft, if applicable, for the secondary donor site

It is important to note that there are currently no relevant Medicare coverage and documentation policies. For private payer claim submission, check directly with the private payer for specific documentation requirement guidance.

When a surgical defect created by Mohs surgery requires tissue transfer or rearrangement, documentation should include the size of the primary lesion and measurement of the primary defect or other relevant measurements. Post-operative photographic documentation of the defect is essential.

CPT coding for ATT or rearrangement

CPT coding guidance for codes 14000-14061 stipulates that these codes are reported based on both the anatomical site and the size of the defect repaired, not the size of the tissue flap used. The defect size is measured in square centimeters.

The code descriptors allow for adjacent tissue transfer or rearrangement of a defect measuring 10 sq cm or less, and also for defects measuring 10.1 sq cm to 30.0 sq cm. For example, CPT Assistant of July 1999, page 3, states that a rotation flap performed to close a 2 sq cm wound of the upper back would be reported using CPT code 14000, Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less.

CPT code 14300, Adjacent tissue transfer or rearrangement, more than 30 sq cm, unusual or complicated, any area, as stated in the code descriptor, should be reported when the size of the defect is greater than 30 sq cm. Additionally, this code may be reported when the dermatologist performs an unusual or complex tissue transfer or rearrangement.

• CPT and CMS do not define unusual or complicated ATT or rearrangement procedures; instead, this determination should be made by the dermatologist.

When ATT or rearrangement is performed on the same day as Mohs surgery, the repair is billed without a modifier. Note that the payer will reduce the payment for Mohs and repair done on the same day based on the multiple surgery reduction rule (MSRR). Similarly, if the repair is performed on a day following Mohs surgery, no modifier is required because Mohs has a 0-day global period.

Below are some coding examples illustrating ATT documentation and reporting:

Example 1: Rotation flap for nasal defect closure
A 65-year-old male presents with a 2.5 cm basal cell carcinoma on the nasal tip. After excision, the resultant defect is 3.0 cm in diameter. A rotation flap is designed from the lateral nasal region to close the defect.

Documentation highlights:

• Diagnosis: C44.311 Basal cell carcinoma of skin of nose

• Procedure: Adjacent tissue transfer (rotation flap), nasal tip defect closure

• Defect size: 3.0 cm in diameter (primary defect); secondary defect addressed with local tissue rearrangement

• CPT code: 14060 Adjacent tissue transfer or rearrangement, eyelids, nose, ears, and/or lips; defect 10 sq cm or less

Example 2: Z-plasty for scar revision on the forearm
A 40-year-old female presents with a hypertrophic scar on the forearm measuring 5.5 cm. A Z-plasty is performed to improve functional mobility.

Documentation highlights:

• Diagnosis: L91.0 Hypertrophic scar

• Procedure: Z-plasty for contracture release and improved mobility

• Defect size: 5.5 cm linear scar; Z-plasty technique used for tissue redistribution

• CPT code: 14021 Adjacent tissue transfer or rearrangement, scalp, arms, and/or legs; defect 10.1 sq cm to 30.0 sq cm

Example 3: Transposition flap for cheek defect closure
A 72-year-old female undergoes Mohs surgery for a 4.5 cm squamous cell carcinoma on the cheek. A transposition flap is utilized to close the defect.

Documentation highlights:

• Diagnosis: C44.329 Squamous cell carcinoma of skin of other parts of face

• Procedure: Transposition flap for defect closure following tumor excision

• Defect size: 4.5 cm diameter; transposition flap measured at 15 sq cm

• CPT code: 14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm or less.

In conclusion, accurate documentation and reporting of ATT and tissue rearrangement procedures are essential for appropriate reimbursement and compliance with coding guidelines. Dermatologists must ensure they maintain thorough and succinct medical record documentation that includes precise defect size measurements and appropriate CPT code selection. By following these best practices, dermatologists can minimize claim denials and support the medical necessity of these reconstructive procedures.

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