• Transgender Breast Augmentation:
• Covered by Medicaid and Medicare, military, most private payers
• Breast reconstruction has its separate code for women with breast cancer
• “bilateral augmentation mammaplasty with prosthetic implant” is the code for transgender breast augmentation.
• Considered to be reconstructive in this population
• Breast Reconstruction Coding:
• Replacement of tissue expander with permanent prosthesis is the CPT code for tissue expander to implant. 
• This includes excision of mastectomy scar.
• Coding for revision of reconstructed breast is only after reconstruction (not stage II with implant placement).
• Fat grafting is a separate code: 20926 (Tissue grafts or other) and is used for fat grafting for pole deformities. No other codes necessary for fat grafting (like fat harvest etc).
• Breast reconstruction with free flap: code includes rib resection, microscope use, complex closure, flap harvest, shaping of breast.
• Other separated codes: May code for use of indocyanine green separately (not interpretation and report)
• May code for any hernia repair that is not created by flap defect.
• Rhinoplasty coding:
• Septoplasty: use this code for septoplasty only including submucous resection and harvest of cartilage.
• For spreader graft placement for internal valve collapse use vestibular stenosis code if performing septoplasty in conjunction as this already includes septal cartilage harvest.
• Rhinoplasty code involves lower alar cartilages, bony pyramid.
• Facial fractures coding:
• ZMC (zygomaticomaxillary) complex fractures are classified as ORIF of malar fracture or “complex” malar fracture
• Complex is necessitated if there are multiple incisions or if the fracture crosses the infraorbital foramen
• Orbital floor fractures if fixed are coded separately even though they are common in ZMC fractures
• Code includes repair with periorbital approach with alloplastic implant
• General Coding
• Random pattern flaps (IE rhomboid flaps) are coded as adjacent tissue transfer. If this is coded the excision of lesion is not separately reportable (separate reporting would be considered unbundling)
• Size of closure or tissue rearrangement includes multiplying defect (size of defect parameters multiplied + size of flap parameters multiplied). 
• The size of reconstruction of the flap defect not included in coding as it is already included by the secondary defect measurement.
• However reconstruction techniques of the donor site is included in coding
• Flaps based on an axial pattern named vessel (IE karapandzic flap based on facial artery) is coded as a musculocutaneous flap or fasciocutaneous flap depending on components.
• Medicare and Medicaid Reimbursements: (mostly followed by third party payers)
• Global surgical package is a single payment for all care associated with a surgical procedure (some things are not separately billable)
• Services not included in the global package include unrelated visits, unrelated surgeries, and initial evaluation.
• Global period: for major surgery is 90 days and includes post-operative care and procedures
• Pre-operative visits after surgery decision made
• All post-surgical pain care
• Supplies and procedures
• Suture removal
• Post-Operative Visits: (global period where no additional fees are payable)
• Major surgery has a 90 day global period
• Exception includes complications that return to operating room (hematoma, infection)

Statistical Analysis:

• Common measures of central tendency: Mean (statistical average, prone to change when data is highly skewed) Median (the exact middle value, preferred with highly skewed data), Mode (most frequently occurring score in a set of scores)
• Range: distance between minimum and maximum value
• Standard deviation: how spread out the values are in a data set
• Categorical values (cannot be quantified) usually assessed by nonparametric statistics
• Continuous variable: a variable that gives a score for each subject (blood pressure, cholesterol), use parametric to assess
• Parametric tests assume that the data are normally distributed and nonparametric tests are typically more stringent because they are based on the assumption of nonnormal distribution
• Parametric ex: T test, ANOVA, Chi Square
• Non-Parametric: ordinal or nominal, Mann-Whitney U test, fischer exact test, wilcoxon matched pairs test
• P-Value: probability that the outcome would have occurred by chance (set at 0.05)
• Confidence interval: range of values around a sample mean within which the researcher can be certain contains true mean of population
• Sensitivity: the probability that a patient with a disease will have a positive test result
• Specificity: the probability that a patient without a disease will have a negative test result
• Positive predictive value: the probability that a patient with a positive test result has the disease (specificity) 
• The negative predictive value: the probability that a patient with a negative test result does not have the disease (sensitivity)
• Types of Error
• Type I error: probability of falsely rejecting the null hypothesis (when a researcher concludes that there is a difference between two conditions when there is no difference
• Type II error: probability of failing to reject null hypothesis when it is true, and the researcher concludes there is no difference between two conditions when there is a real difference
• Null hypothesis: that there is no real difference between the two groups
• Power: the term that refers to the statistical likelihood that a researcher will find a significant effect that exists based on the sample size and number of variables