Monthly Hyperbaric Compliance Series
June 2008
Compromised ‘Skin Flaps’: Yes or No?
Exactly what constitutes a skin flap has been the topic of considerable discussion and confusion. In some cases the issue is easily reconcilable. One example would be the repair of a chest wall defect with a Transverse Rectus Abdominis Myocutaneous (TRAM) flap. Other cases are less obvious. One example would be the primary coverage of a below knee amputation site by the sparing of posterially-based skin during the ‘design’ of the amputation.
Common definitions of skin flaps refer, in part, to the fact that the skin is being moved to an anatomic site that it did not previously exist or cover. Clearly, this would include both of the above examples, and would extend to any rotational coverage of an adjacent (even relatively minor) defect, the primary closure of a toe amputation, for example, as discussed in the April 2008 issue of this series.
What about that saphenous vein donor site? The hyperbaric service is not infrequently called into consultation when there are obvious signs of healing compromise, perhaps extending to wound dehiscence. In search of a ‘medically necessary’ indication for HBO therapy it might be reasonable to categorize this problem as a compromised skin flap. After all, full thickness skin is involved. However, involved skin has been brought back to its original location. Accordingly, it is not likely to meet the test of being relocated to a site that it did not previously cover. It would not, therefore, be considered a skin flap and for the purpose of hyperbaric medicine referral, not therefore a compromised skin flap. Medicare post-payment reviews have upheld this position by demanding repayment from hyperbaric providers.
This latter example, the incisional site reapproximation does not necessary rule out HBO completely, however. It is a problem wound. If local and reversible hypoxia can be demonstrated then a pre-authorization request to non-Medicare insurers would be a reasonable course of action.
Previous Monthly Compliance Series: