Medical ERA denying Complex Closure and Advanced Tissue Transfer

Complex Repairs and Adjacent Tissue Transfers: Why Payers Deny Them

AUTHOR’S NOTE:  This article provides another example of the critical role the “right words” play when it comes to avoiding denials — especially given insurers’ widespread use of computer-assisted coding (CAC) applications to facilitate the claims process. To learn more about an app designed to analyze the “CAC-friendliness” of any procedure note, please visit https://claimz.ai/features.

Complex repairs and adjacent tissue transfers (ATT) are so routine in dermatologic surgery, insurers should be well aware of the procedures as well as their documentation. Over the past few years, though, these two repairs have been the target of denials — not because the procedure was performed incorrectly, but because insurers are looking for very specific language in our notes.

Let’s talk about why they’re happening and what you can do to protect your claims.

“Defect Diameter” and “Undermining” Requirement

CPT makes it clear: complex repair isn’t just layered closure. What usually sets it apart is extensive undermining.¹


Official CPT definition of complex repair:

“Complex repair includes the repair of wounds requiring more than layered closure, such as scar revision, debridement… or extensive undermining.”¹

CPT description of “extensive undermining”:

“Undermining equal to or greater than the maximum width of the defect, measured perpendicular to the closure line along at least one entire edge.”¹

Because of their official descriptions, payers may deny claims unless the note includes:

  • Defect size in centimeters, and…
  • Undermining distance and direction

Without these details, insurers have argued that “there’s no proof the undermining was extensive enough.”

The “Closure of Superficial Fascia” Problem

In addition to the above strict requirements, some payers have added additional requirements that CPT never intended. For example, UnitedHealthcare (UHC) has denied complex repairs unless the note specifically included the phrase “closure of superficial fascia.”²


The problem with this is that the phrase “closure of superficial fascia” actually belongs to intermediate repair (not complex repairs).


CPT’s definition of intermediate repair:

“...includes the repair of wounds that require layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia,”¹

By requiring “fascia closure” for complex repairs, UHC has misinterpreted (and misapplied) the official Current Procedural Terminology code set. The American Academy of Dermatology (AAD) has raised this issue with insurers,² but until payers correct it, many practices find that adding the phrase into their documentation keeps the claim moving.

Why ATTs Get Downcoded

Denials of adjacent tissue transfers usually arise from phrasing taken from the NCCI Policy Manual.³


NCCI states:

“Adjacent tissue transfer or rearrangement requires additional incisions to mobilize tissue. The work includes excision (if performed), incisions, undermining, and the transfer or rearrangement of tissue to close the defect.”³

And it’s this NCCI phrasing which serves as the origin of the two “right words” auditors want to see:

  • “Additional incisions”
  • “Incised and carried over to close the defect”

If those exact words aren’t in your note, payers may downcode your ATT to a complex repair.

UHC’s Extra Twist: Location of Incisions

In addition to the above phrasing, UHC has gone even further — requiring not just the mention of “additional incisions” but also where those incisions were placed.²


Consider the following...


Phrasing prone to trigger a UHC denial:

“Adjacent tissue transfer performed. Tissue incised and carried over to close the defect.”

Phrasing which is more “UHC-friendly”:

“Adjacent tissue transfer performed. Tissue incised along the lateral margin of the defect, with an additional relaxing incision placed superiorly. The tissue was then carried over to close the central defect.”

The second version satisfies both NCCI’s requirements and UHC’s extra demand.

Practical Documentation Tips

For Complex Repairs:

  • Always document defect size in cm.
  • Note undermining length and direction.
  • Use layered closure language: “closure performed in layers, including dermis and subcutaneous tissue.”
  • Add anatomic qualifiers (helical rim, vermilion border, cartilage, bone exposure) when present — these alone can justify complex repair.⁴

For Adjacent Tissue Transfers:

  • Use NCCI’s exact wording: “additional incisions were made, and tissue was incised and carried over to close the defect.”³
  • Be specific about where the incisions were placed.²
  • Record both defect size and flap area — payers may request it.

Consideration for EMR Templates:

  • Add structured fields for defect size, undermining, fascia involvement, and ATT incision location.
  • Save payer-preferred phrases in macros so they’re always available.

Bottom Line

Insurers aren’t denying your surgical skill — they’re denying your documentation. Until payer policies fully align with CPT, the safest move is to document in their language first, and yours second.

By embedding CPT definitions and NCCI wording into your op notes, you’ll cut denials, get paid faster, and avoid the cycle of unnecessary appeals.


For a checklist summary of the tips described, please visit:


https://my.frontdeskcourse.com/complex-repairs-and-adjacent-tissue-transfers-why-payers-deny-them

References

  1. CPT® Professional 2024. American Medical Association. Definitions for Intermediate and Complex Repair.
  2. AAD Meeting Presentation — Getting Paid & Passing Audits. Mollie MacCormack, MD. Documentation pitfalls with UHC requirements (closure of superficial fascia, incision location).
  3. NCCI Policy Manual for Medicare Services (2024). Chapter III: Integumentary System — Adjacent Tissue Transfer.
  4. AAD Meeting Presentation — From Novice to Guru. Curtis Asbury, MD. Complex repair documentation details (undermining, anatomic qualifiers).

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