Flaps, grafts & Medicare items

ACCO guide to item numbers, flaps and grafts

This page has been updated in November 2016 following the change in Medicare item numbers for skin cancer surgery.

The ACCO Board supports the changes introduced by the Federal Government, even those changes that the AMA has questioned. (See below). The Federal Government changes reflect the ACCO policy on on item numbers reflecting best practice.

Medicare Item numbers
ACCO is frequently asked for guidance with item number choices for random pattern flap closures. The College has considered these requests and offers the following "ready reckoner" to assist.

Front page of ready reckonerBack page of ready reckoner. We suggest you download these two pages, laminate them back to back and have them readily available.

Some ACCO members have asked question regarding the ready reckoner:-

The small numbers in brackets coloured red are relative value numbers. The number determines roughly the value Medicare places on the procedure relative to a skin biopsy.

FULL DETAILS: If you would like the full Medicare description of procedural item numbers pertinent to skin cancer management in Australia, our 10 page full listing is available here.

HOSPITAL ASPECTS: Under the new arrangements, small benign lesions being excised may not be eligible for hospital funding. Similarly, removing a small skin cancer on easy areas where the resultant defect is less than 15 mm does not qualify the procedure for funding in a hospital. ACCO supports these changes. These very small easy procedures can easily be performed in procedure rooms in medical centres. In the main procedures such as these being undertaken in a hospital is an overkill and a waste of health dollar resources. There will be unusual exceptions. For example, small children or patients with an intellectual impairment may at times need a hospital and an anaesthetist to effect even these small procedures. The items not appropriate for hospital management under than such circumstances are identified in our "ready reckoner".

DEFECT SIZE: How do we verify the defect size? You can use a ruler. But there is another trick using a 5 cent piece.

The 5 cent coin is 19.4 mm in diameter. Hence a 6 mm defect on a tough site should be a third of the diameter of the coin.

See photo below of a defect on a tough zone that is confirmed as over 6 mm in diameter.


For intermediate surgical zones, the defect must be greater than 2/3rds the diameter of a 5 cent coin to be considered 14 mm in diameter or greater.

For easy areas, a 30 mm defect needs to be at least 1 1/2 times the diameter of a 5 cent coin. See photo.


This defect on the shoulder is not 1.5 times the diameter of the coin and hence should be considered a 15 - 30 mm defect.

Tip:- Sterilise a 5 cent coin with every needle holder. Then you will always have a size scale for every defect.

WHEN COULD A SKIN FLAP BE CONSIDERED?

Following excision of skin cancer / skin lesion, most defects can be closed directly as an ellipse or variation thereof.
At times, direct closure will be considered inappropriate or inadequate for one of many possible reasons. In these circumstances, the clinician may choose to close the defect with a flap or graft.

These guidelines have been prepared by the Australasian College of Cutaneous Oncology (ACCO) as a reference guide for doctors managing skin cancer.

Before deciding to close a defect with a flap or graft, the clinician should be able to identify a clear clinical indication for not using direct closure in that circumstance.

Most skin flap closure indications are above the neck or distal to or including the knee or wrist. Outside of these areas, sheer size may necessitate flap for optimum outcome. Medicare considers a defect must be at least 30 mm in diameter in these easy areas to justify flap consideration. ACCO agrees. 

When a lesion is locally excised for the purposes of obtaining histologic diagnosis, every effort should be made to close the defect directly rather than with a flap or graft repair. The clinician should bear in mind the subsequent treatment the patient may require if melanoma or other malignancy is confirmed.

We list here the possible specific issues that may steer the clinician away from closure directly towards closure with a flap or graft:
Size: Sheer size of the defect may indicate a need for skin flap / graft repair. In this guide, defect diameters are quoted in mm and refer to the average diameter of the defect required to excise the tumour and with adequate margins following lesion excision. Ellipse tails, burrows triangles and other examples of skin wastage are not considered when determining defect size. 
Location: Size may mitigate against direct closure in any location on the body. The point at which a defect is considered too large for direct closure depends very much on location. A defect as small as 6 mm on the nose may require a flap or graft closure. A defect down low on the alar of the nose contiguous with the free margin of the nose may require a flap repair at times even if the defect is less than 6 mm. (In this scenario the correct Medicare number to charge for the flap is 45202 rather than 45201.)  A defect on the trunk of up to 30 mm and not over a joint can usually be closed directly without compromise to patient outcome.

Contour distortion: Direct closure can lead to distortion that may be cosmetically inferior to a flap repair. For example, large defects on the cheek can lead to a permanent concave distortion that is often considered unacceptable by the patient over the long term. Where the clinician considers this risk problematic a flap closure may be indicated.
Asymmetry risk: Especially on the face, even slight asymmetry between the right and left side can be cosmetically suboptimal. For example, alar elevation of 2mm on one side compared to the other can often be quite noticeable and poorly accepted by the patient. Similarly, upper lip elevation of 2mm on one side compared to the other is usually quite noticeable and patients may consider this unacceptable.
Z effect: This refers to defects over joints. A linear scar can contract causing long term functional impairment over a joint. When this is considered a risk, a flap closure that involves a “Z effect” may be considered. These closures have a zig zag type outcome that better accommodates stretch and reduces contracture risk in the long term post-operative setting. Flap closures recognised for their “Z effect” include O-S, O-Z and ROM flaps. “Z effect” contrasts with the “Z plasty” which has minimal role in skin cancer surgery other than as an option when considering management of problematic resultant contractures. Usage of a flap with a “Z effect” now may prevent the need to do a “Z plasty” later.
Skin wastage: Skin excised for tumour removal includes three components; the tumour, the margin considered appropriate to excise the tumour and skin “wastage”. This refers to the two roughly triangle shaped pieces of skin that are removed at each end of an ellipse. This skin need not be removed for adequate tumour clearance but is removed because that is how one effects an ellipse. A typical elliptical excision can involve removing about twice the area of skin that is actually required to clear a tumour including its necessary margin. This is usually not a bad thing and the term “wastage” is perhaps unnecessarily pejorative. Clinicians effect ellipses all the time without regard to skin wastage. But at times skin wastage is an issue. Skin may be so tight that the clinician wishes only to remove the tumour and its margin so as the resultant defect is as small as possible. Locations where skin wastage is frequently considered in tumour management include the leg and the scalp and often the hand and foot. Closure techniques that minimise skin wastage include skin grafts, O-S, O-Z, pinwheel and ROM flaps.
Cosmetic border: These are the lines that border different zones on the face. For example there are cosmetic borders where the cheek meets the nose and where the forehead meets the hairline. As a general rule, clinicians try to avoid unnecessarily crossing cosmetic borders. Scars are frequently suboptimal when these lines are crossed. Often flap design can avoid such issues. Flaps are frequently designed to have lines along cosmetic borders.
Cosmetic sub zones: Within each zone on the face there are sub zones that can have their own cosmetic implications. For example, on the nose the nasal dorsum, nasal tip and nasal alar each have their own cosmetic implications. Closure of a nasal tip defect might involve a flap design that avoids crossing in to alar sub zone.
Two cosmetic zones: Sometimes tumours occur at cosmetic borders or effecting their excision involves creating a defect within or across two cosmetic zones. In this situation, the defect is often regarded as two separate defects and each zone component may be closed with its own approach. For example, a defect involving lateral nasal side wall as well as cheek may have the cheek component closed with cheek skin and nasal defect closed with nose skin. One or other or both components of such closure may involve a skin flap repair. The design will usually be planned so that no closure component crosses the cosmetic border.
Cosmetic line: Within cosmetic zones there are often other lines that have an impact on closure design. For example, horizontal wrinkle lines on the forehead can be useful to hide scar lines. Flaps are frequently designed on the forehead to blend in with these lines.
Occupation / lifestyle: Individual patient considerations play a part in the design of defect closure. For example a problematic defect on the dorsum of the hand of a manual worker wanting to return to full work promptly may have clinical differences from a similar defect on another person. In such a circumstance, avoiding tissue wastage and a flap with a Z effect may be considered rather than direct closure.
Patient preferences: Sometimes patients prefer certain surgical approaches over other approaches. When several options are considered reasonable by the clinician, these should be discussed with the patient. Of note, some patients prefer grafts whenever a flap versus graft is considered. Other patients prefer flaps in this situation. This request may relate to their former experiences or advice from others. A problem arises when a patient requests a flap closure when the clinician feels such is not indicated on clinical grounds. If a flap is effected in these circumstances an out of pocket premium might be charged to the patient but a Medicare flap item number should not be charged.
Other: This list is not meant to be exhaustive. Other individual circumstances will have a bearing on decisions regarding closure. There will be other times when direct closure would be considered suboptimal by the clinician. One should bear in mind that in surgery it is best to try to “do it right the first time”. If it is considered an issue may arise later that might require scar or wound revision, consider whether a different approach today might minimise that later risk.

Flap versus graft?
Grafts are generally easier to perform than flaps, other than the simplest flaps. It is a trap to find yourself closing many defects with grafts simply because one’s knowledge and experience of a range of flap closures is limited. For those experienced, it would be unlikely to have as many as one defect closed with a graft for every 5 defects closed with skin flaps. Using grafts more frequently than this may indicate a need for greater training in skin flap techniques / variety, etc. When a defect can be closed with either flap or graft, flaps generally produce better cosmetic results. Grafts are generally reserved for when both direct closure and flaps are considered inappropriate.

Flap rates will vary considerably from one doctor to another. Doctors managing defects on all areas of the head and neck including the most difficult defects will be expected to have higher rates of skin flap usage than those who refer some or all of their head and neck tumours / defects. As a corollary, those who accept referrals for head and neck tumours or defects will inevitably be effecting more flap repairs than other doctors. A doctor managing only the most difficult head and neck tumours may have substantial usage of skin flaps and grafts. ACCO therefore does not consider that there is any “correct flap rate” but rather ACCO is concerned that flaps are used only where indicated and when appropriate to best meeting the patient’s needs.

Planning:
Positive histologic margins can unexpectedly occur when excising skin tumours, even when the clinician has planned liberal clinical margins. At times the defect will have been closed with a flap repair. Because this circumstance can happen with any type of flap repair, the clinician should be able to correlate where the skin edge with a positive margin is now compared to the location at the time of original defect prior to flap mobilization. The clinician must be able to identify which areas of skin in the new location need further excision to address such positive margins. If the clinician is not confident that original and final margins can be correlated with confidence, the flap surgery should not be effected.

It is desirable to have photographs or a detailed preoperative diagram of tumours excised that require a flap closure. This assists documentation and can prove valuable when unexpected positive margins are detailed in histology reports. A ruler or other device to determine scale can be useful in clinical photographs. A sterile 5 cent coin is also a useful size indicator. It is 19.4mm in diameter.

Ideally, every lesion removed with the intent of wide excision should be orientated prior to placement in the specimen jar for histology. Either a “nick” or suture at a point denoted 12 O’clock is recommended.

DISCLAIMERS

Training / certification: ACCO has demonstrated that College certification in skin cancer surgery level or higher has been shown to train doctors to effectively and safely undertake skin flap / graft surgery as a component of clinical practice.

This guide including advice on item number usage is meant to assist doctors understanding the Medicare schedule. It does not replace the schedule and does include all the criteria for item number selection.

ACCO takes no responsibility for doctors using this guide selecting item numbers to charge for procedures. ACCO has updated and reviewed this page so as to be as accurate as we understand. We cannot take responsibility for inadvertent errors or admissions.

© Australasian College of Cutaneous Oncology 2016