FLAPS (Skin and/or Deep tissue)

 

 

 

The regions listed refer to the recipient area (not the donor site) when a flap is attached in a transfer or to a final site.
The regions listed refer to a donor site when a tube is formed for later transfer or when a “delay” of flap occurs before the transfer. Codes 15733-15738 are described by the donor site of the muscle, myocutaneous, or fasciocutaneous flap. Codes 15570-15738 do not include extensive immobilization (eg, large plaster casts and other immobilizing devices are considered additional separate procedures). A repair of a donor site requiring a skin graft or local flaps is considered an additional separate procedure. (For microvascular flaps, see 15756-15758).
(For flaps without the inclusion of a vascular pedicle, see 15570-15576) .

(For adjacent tissue transfer flaps, see 14000-14302)

A flap, in medical terms, refers to a piece of tissue that is partially detached from its original blood supply and moved to another area of the body. Flaps are commonly used in reconstructive and plastic surgery to repair defects, replace damaged or missing tissues, and improve the function and appearance of a specific area. There are different types of flaps, including skin flaps and deep tissue flaps, each serving specific purposes.

1. Skin Flap:
   • A skin flap involves transferring a section of skin along with its underlying blood vessels to a different location.
   • Skin flaps are used for reconstructing areas where there is skin loss due to injury, trauma, surgery, or congenital deformities.
   • There are various types of skin flaps, including local flaps (adjacent to the defect), regional flaps (from a nearby but non-adjacent area), and distant flaps (from a distant part of the body).
2. Deep Tissue Flap:
   • A deep tissue flap involves the transfer of not only the skin but also underlying fat, muscle, or other tissues along with their blood supply.
   • These flaps are used when reconstruction requires more than just replacing skin, such as in cases where significant volume or structural support is needed.
   • Deep tissue flaps are often used in complex reconstructive surgeries, such as breast reconstruction after mastectomy or repairing defects involving deeper structures.

The key aspect of a flap procedure is maintaining a blood supply to the tissue being transferred. This is critical for the survival of the flap in its new location. Microsurgery techniques are commonly employed to reconnect blood vessels in the flap to those at the recipient site, ensuring proper blood flow.

 

CPT CODE – 15570 Formation of direct or tubed pedicle, with or without transfer; trunk

1. • CPT code 15570 is used for the formation of a direct or tubed pedicle, with or without transfer.
   • The procedure is performed on the trunk.
2. Body Area:
   • This code specifically involves the trunk, indicating that the procedure is performed on the torso.
3. Pedicle Formation:
   • The code includes the formation of a direct or tubed pedicle, which involves creating a flap of tissue with its blood supply that can be used for reconstruction.
4. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Include details about the type of pedicle formed, whether it involves a direct or tubed pedicle and the specific location on the trunk.

Example:

Scenario: A patient undergoes reconstructive surgery following a mastectomy, and a pedicle flap is formed to reconstruct the breast area. The procedure involves the trunk, and the pedicle is formed without transfer.

Code Assignment:

• CPT Code: 15570
• Description: Formation of direct or tubed pedicle, with or without transfer; trunk.

Documentation: The medical record should include the following information:

• Specifics about the pedicle formation
• Type of pedicle (direct or tubed)
• Location: Trunk
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the formation of a direct or tubed pedicle procedure described by CPT code 15570.

 

CPT CODE  15572  Formation of direct or tubed pedicle, with or without transfer scalp, arms, or leg

CPT CODE  15574  Formation of direct or tubed pedicle, with or without transfer  forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet

CPT CODE  15576  Formation of direct or tubed pedicle, with or without transfer eyelids, nose, ears, lips, or intraoral

CPT CODE  15600 Delay of flap or sectioning of flap (division and inset); trunk

1. • CPT code 15600 is used for the delay of a flap or sectioning of a flap (division and inset).
   • The procedure is performed on the trunk.
2. Flap Delay or Sectioning:
   • This code involves the intentional delay of a flap or the sectioning of a flap, which may be necessary for various reconstructive or plastic surgery purposes.
3. Body Area:
   • The procedure is performed on the trunk, indicating that it involves the torso.
4. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Include details about why the delay or sectioning is necessary and the specific location on the trunk.

Example:

Scenario: A patient is scheduled for reconstructive surgery involving the abdomen, and it is determined that delaying the flap will optimize the outcome. The surgeon performs a flap delay procedure on the trunk.

Code Assignment:

• CPT Code: 15600
• Description: Delay of flap or sectioning of flap (division and inset); at trunk.

Documentation: The medical record should include the following information:

• Reason for flap delay or sectioning
• Specifics about the procedure performed
• Location: Trunk
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the delay of a flap or sectioning of a flap procedure described by CPT code 15600.

 

CPT CODE  15610 Delay of flap or sectioning of flap (division and inset) at scalp, arms, or legs

CPT CODE  15620  Delay of flap or sectioning of flap (division and inset) at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet

CPT CODE  15630 Delay of flap or sectioning of flap (division and inset)  at eyelids, nose, ears, or lips

CPT CODE  15650 Transfer, intermediate, of any pedicle flap (eg, abdomen wrist, Walking tube), any location

(For eyelids, nose, ears, or lips, see also anatomical area)

(For revision, defeating, or rearranging of transferred pedicle flap or skin graft, see 13100-14302)

1. • CPT code 15650 is used for the transfer, intermediate, of any pedicle flap.
   • The code encompasses the transfer of a pedicle flap from one location to another.
2. Pedicle Flap Transfer:
   • This code involves the transfer of a pedicle flap, which is a flap of tissue with its blood supply, from one location to another.
   • The term “intermediate” suggests that it is a transfer involving an intermediate distance.
3. Location:
   • This code does not specify a particular body area, allowing flexibility for the transfer from any location to any other location.
4. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Include details about the specific pedicle flap being transferred, the locations involved, and any specific conditions or complications.

Example:

Scenario: A patient requires reconstruction of a facial defect using a pedicle flap from the forearm. The surgeon performs an intermediate transfer of the pedicle flap.

Code Assignment:

• CPT Code: 15650
• Description: Transfer, intermediate, of any pedicle flap (e.g., abdomen wrist, Walking tube), any location.

Documentation: The medical record should include the following information:

• Details about the specific pedicle flap used
• Transfer from: Forearm
• Transfer to: Face
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the intermediate transfer of a pedicle flap procedure described by CPT code 15650.

 

CPT CODE  15730 Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s)

1. • CPT code 15730 is used for the midface flap, specifically the zygomaticofacial flap, with preservation of vascular pedicle(s).
   • The code involves the creation and use of a flap from the midface region, known as the zygomaticofacial flap, with a focus on preserving vascular pedicles.
2. Procedure Description:
   • This code is typically used for reconstructive surgery involving the midface area, and specifically, the zygomaticofacial region.
   • The preservation of vascular pedicles indicates that the flap is designed to maintain its blood supply.
3. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Include details about the specific midface flap used (zygomaticofacial flap), the preservation of vascular pedicles, and any specific conditions or complications.

Example:

Scenario: A patient undergoes reconstructive surgery for a midface defect following trauma, and a zygomaticofacial flap is utilized, preserving its vascular pedicle(s).

Code Assignment:

• CPT Code: 15730
• Description: Midface flap (i.e., zygomaticofacial flap) with preservation of vascular pedicle(s).

Documentation: The medical record should include the following information:

• Specifics about the midface flap used (zygomaticofacial flap)
• Confirmation of preservation of vascular pedicles
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the midface flap procedure described by CPT code 15730.

CPT CODE  15731 Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap)

(For muscle, myocutaneous, or fasciocutaneous flap of the head or neck, use 15733)

1. • CPT code 15731 is used for the forehead flap with preservation of vascular pedicle.
   • The code involves the creation and use of a flap from the forehead, such as an axial pattern flap or paramedian forehead flap, with a focus on preserving vascular pedicles.
2. Procedure Description:
   • This code is typically used for reconstructive surgery involving the forehead area.
   • The preservation of vascular pedicle(s) indicates that the flap is designed to maintain its blood supply.
3. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Include details about the specific forehead flap used (e.g., axial pattern flap, paramedian forehead flap), the preservation of vascular pedicles, and any specific conditions or complications.

Example:

Scenario: A patient undergoes reconstructive surgery for a nasal defect, and a forehead flap, specifically a paramedian forehead flap, is utilized for the preservation of its vascular pedicle.

Code Assignment:

• CPT Code: 15731
• Description: Forehead flap with preservation of vascular pedicle (e.g., axial pattern flap, paramedian forehead flap).

Documentation: The medical record should include the following information:

• Specifics about the forehead flap used (paramedian forehead flap)
• Confirmation of preservation of vascular pedicle(s)
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the forehead flap procedure described by CPT code 15731.

CPT CODE  15733 Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae)

(For forehead flap with preservation of vascular pedicle, use 15731)

(For anterior pericranial flap on named vascular pedicle, for the repair of the extracranial defect, use 15731)

(For repair of head and neck defects using non-axial pattern advancement flaps [including lesion] and/or repair by adjacent tissue transfer or rearrangement [eg, Z-plasty, W-plasty, V-Y plasty, rotation flap, random island flap, advancement flap], see 14040, 14041, 14060, 14061, 14301, 14302) 15734 trunk

1. • CPT code 15733 is used for a muscle, myocutaneous, or fasciocutaneous flap procedure.
   • The flap is performed on the head and neck.
   • The flap involves a named vascular pedicle, such as buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, or levator scapulae.
2. Procedure Description:
   • This code is typically used for reconstructive surgery involving the head and neck.
   • The procedure involves the transfer of muscle, mucocutaneous, or fasciocutaneous tissue with a specific vascular pedicle.
3. Named Vascular Pedicle:
   • The vascular pedicle indicates the specific muscle or structure from which the flap is derived and its associated blood supply.
4. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Include details about the specific muscle or structure used for the flap (e.g., buccinators, genioglossus), the preservation of the named vascular pedicle, and any specific conditions or complications.

Example:

Scenario: A patient undergoes reconstructive surgery for a defect in the oral cavity, and a myocutaneous flap is harvested from the genioglossus muscle with preservation of its named vascular pedicle.

Code Assignment:

• CPT Code: 15733
• Description: Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (i.e., buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae).

Documentation: The medical record should include the following information:

• Specifics about the flap used (myocutaneous flap from the genioglossus muscle)
• Confirmation of preservation of the named vascular pedicle (genioglossus)
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the muscle, myocutaneous, or fasciocutaneous flap procedure described by CPT code 15733.

CPT CODE  15736 Muscle, myocutaneous, or fasciocutaneous flap upper extremity

CPT CODE  15738 Muscle, myocutaneous, or fasciocutaneous flap lower extremity

Other Flaps and Grafts

 

CPT Code 15740 describes a cutaneous flap, transposed into a nearby but not immediately adjacent defect, with a pedicle that incorporates an anatomically named axial vessel into its design. The flap is typically transferred through a tunnel underneath the skin and sutured into its new position. The donor site is closed directly. Neurovascular pedicle procedures are reported with 15750. This code includes not only skin but also a functional motor or sensory nerve(s). The flap serves to reinnervate a damaged portion of the body dependent on touch or movement (eg, thumb).

Repair of the donor site requiring skin graft or local flaps should be reported as an additional procedure. For random island flaps, V-Y subcutaneous flaps, advancement flaps, and other flaps from adjacent areas without clearly defined anatomically named axial vessels, see 14000-14302.

CPT Code 15769 may be used to report autologous soft tissue grafts, such as fat, dermis, fascia, or other soft tissues, which are harvested from the patient using an excisional technique. The autologous soft tissue grafts are then placed into a defect during the same operation. Autologous grafts that are already defined in the CPT code set, including skin, bone, nerve, tendon, fascia lata, or vessels, should be reported with the specific codes for each tissue type. For harvesting, preparation, or injection(s) of platelet-rich plasma, use 0232T.

CPT Codes 15771, 15772, 15773, and 15774 may be used to report autologous fat grafting when the adipose cells are harvested via a liposuction technique, prepared with minimal manipulation, and then injected via a cannula in multiple small aliquots to the defect. The regions listed refer to the recipient area (not the donor site). Volumes are based on total injectate. For multiple sites of injection, sum the total volume of injectate to anatomic sites that are grouped into the same code descriptor. Do not report 11950, 11951, 11952, or 11954 in conjunction with 15771, 15772, 15773, or 15774, for the same anatomic site.

CPT CODE  15740 Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel

1. • CPT code 15740 is used for a flap procedure with an island pedicle.
   • The procedure requires the identification and dissection of an anatomically named axial vessel.
2. Procedure Description:
   • This code is typically used for reconstructive surgery involving the creation of a flap with an island pedicle.
   • The flap is vascularized by an anatomically named axial vessel, and the procedure involves the identification and dissection of this vessel.
3. Anatomically Named Axial Vessel:
   • The code emphasizes the importance of an anatomically named axial vessel supplying the island pedicle.
4. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Include details about the specific flap created, the island pedicle, the identification and dissection of the anatomically named axial vessel, and any specific conditions or complications.

Example:

Scenario: A patient requires reconstruction following trauma and a flap with an island pedicle is created using the anterior thigh region. The procedure involves the identification and dissection of the descending branch of the lateral circumflex femoral artery.

Code Assignment:

• CPT Code: 15740
• Description: Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel.

Documentation: The medical record should include the following information:

• Specifics about the flap created (using the anterior thigh region)
• Island pedicle
• Anatomically named axial vessel: Descending branch of the lateral circumflex femoral artery
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the flap procedure with an island pedicle described by CPT code 15740.

CPT CODE  15750 Flap; neurovascular pedicle

CPT CODE  15756 Free muscle or myocutaneous flap with microvascular anastomosis

(Do not report code 69990 in addition to code 15756)

1. • CPT code 15756 is used for a free muscle or myocutaneous flap procedure.
   • The procedure involves microvascular anastomosis, indicating that blood vessels are surgically connected under magnification.
2. Procedure Description:
   • This code is typically used for complex reconstructive surgery where a muscle or myocutaneous flap is transferred from one area to another.
   • The procedure involves the use of microvascular anastomosis to establish blood supply in the recipient site.
3. Microvascular Anastomosis:
   • The microvascular anastomosis is a critical component of this procedure and involves the meticulous joining of blood vessels.
4. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Include details about the specific muscle or myocutaneous flap used, the donor and recipient sites, and the microvascular anastomosis. Document any specific conditions or complications.

Example:

Scenario: A patient undergoes reconstruction of a defect in the lower leg due to trauma. A free myocutaneous flap is harvested from the thigh and transferred to the lower leg. Microvascular anastomosis is performed to connect the blood vessels in the flap to those in the lower leg.

Code Assignment:

• CPT Code: 15756
• Description: Free muscle or myocutaneous flap with microvascular anastomosis.

Documentation: The medical record should include the following information:

• Specifics about the flap used (myocutaneous flap from the thigh)
• Donor and recipient sites
• Confirmation of microvascular anastomosis
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the free muscle or myocutaneous flap procedure with microvascular anastomosis described by CPT code 15756.

CPT CODE  15757 Free skin flap with microvascular anastomosis
(Do not report code 69990 in addition to code 15757)

1. • CPT code 15757 is used for a free skin flap procedure.
   • The procedure involves microvascular anastomosis, indicating that blood vessels are surgically connected under magnification.
2. Procedure Description:
   • This code is typically used for reconstructive surgery where a skin flap is transferred from one area to another.
   • The procedure involves the use of microvascular anastomosis to establish blood supply in the recipient site.
3. Microvascular Anastomosis:
   • The microvascular anastomosis is a critical component of this procedure and involves the meticulous joining of blood vessels.
4. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Include details about the specific skin flap used, the donor and recipient sites, and the microvascular anastomosis. Document any specific conditions or complications.

Example:

Scenario: A patient undergoes reconstruction of a facial defect due to skin cancer. A free skin flap is harvested from the upper arm and transferred to the face. Microvascular anastomosis is performed to connect the blood vessels in the flap to those in the facial area.

Code Assignment:

• CPT Code: 15757
• Description: Free skin flap with microvascular anastomosis.

Documentation: The medical record should include the following information:

• Specifics about the skin flap used (from the upper arm)
• Donor and recipient sites
• Confirmation of microvascular anastomosis
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the free skin flap procedure with microvascular anastomosis described by CPT code 15757.

 

CPT CODE  15758 Free fascial flap with microvascular anastomosis
(Do not report code 69990 in addition to code 15758)

1. • CPT code 15758 is used for a free fascial flap procedure.
   • The procedure involves microvascular anastomosis, indicating that blood vessels are surgically connected under magnification.
2. Procedure Description:
   • This code is typically used for reconstructive surgery where a fascial flap is transferred from one area to another.
   • The procedure involves the use of microvascular anastomosis to establish blood supply in the recipient site.
3. Microvascular Anastomosis:
   • The microvascular anastomosis is a critical component of this procedure and involves the meticulous joining of blood vessels.
4. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Include details about the specific fascial flap used, the donor and recipient sites, and the microvascular anastomosis. Document any specific conditions or complications.

Example:

Scenario: A patient undergoes reconstruction of a lower extremity defect due to trauma. A free fascial flap is harvested from the thigh and transferred to the lower leg. Microvascular anastomosis is performed to connect the blood vessels in the flap to those in the lower leg.

Code Assignment:

• CPT Code: 15758
• Description: Free fascial flap with microvascular anastomosis.

Documentation: The medical record should include the following information:

• Specifics about the fascial flap used (from the thigh)
• Donor and recipient sites
• Confirmation of microvascular anastomosis
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the free fascial flap procedure with microvascular anastomosis described by CPT code 15758

 

CPT CODE  15760 Graft; composite (eg, full thickness of external ear or nasal ala), including primary closure, the donor area

1. • CPT code 15760 is used for a composite graft procedure.
   • The composite graft includes the full thickness of an external ear or nasal ala.
   • The procedure includes primary closure of the donor area.
2. Procedure Description:
   • This code is typically used for reconstructive surgery where a composite graft is harvested from one area (external ear or nasal ala) and transferred to another.
   • The graft involves the full thickness of the external ear or nasal ala.
3. Primary Closure of Donor Area:
   • The code specifies that the donor area, from which the composite graft is harvested, should be closed primarily.
4. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Include details about the specific composite graft used, the donor and recipient sites, and the primary closure of the donor area. Document any specific conditions or complications.

Example:

Scenario: A patient undergoes reconstruction of the nasal ala following skin cancer excision. A composite graft is harvested from the ear, including the full thickness of the external ear, and transferred to reconstruct the nasal ala. The donor area is closed primarily.

Code Assignment:

• CPT Code: 15760
• Description: Graft; composite (e.g., full thickness of external ear or nasal ala), including primary closure, donor area.

Documentation: The medical record should include the following information:

• Specifics about the composite graft used (from the external ear)
• Donor and recipient sites
• Primary closure of the donor area
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the composite graft procedure described by CPT code 15760.

 

CPT CODE  15769  Code is out of numerical sequence. See 15760-15772

CPT CODE  15770  Graft; derma-fat-fascia

CPT CODE  # 15769 Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)
(For injection[s] of platelet-rich plasma, use 0232T)

1. • CPT code 15769 is used for grafting of autologous soft tissue.
   • The soft tissue is harvested by direct excision.
   • Examples of the harvested soft tissue include fat, dermis, and fascia.
2. Procedure Description:
   • This code is typically used for procedures where autologous (patient’s own) soft tissue grafting is performed.
   • The soft tissue is obtained through direct excision, and examples of the harvested tissues may include fat, dermis, or fascia.
3. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Specify the type of autologous soft tissue used (e.g., fat, dermis, fascia), the site of harvest, and details about the grafting procedure. Document any specific conditions or complications.

Example:

Scenario: A patient undergoes reconstruction after breast cancer surgery. Autologous fat grafting is performed to enhance the contour of the breast. The fat is harvested by direct excision from the patient’s abdomen.

Code Assignment:

• CPT Code: 15769
• Description: Grafting of autologous soft tissue, other, harvested by direct excision (e.g., fat, dermis, fascia).

Documentation: The medical record should include the following information:

• Type of autologous soft tissue used (fat)
• Site of harvest (abdomen)
• Details about the grafting procedure
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the autologous soft tissue grafting procedure described by CPT code 15769.

 

CPT CODE  15771 Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate
(Report 15771 only once per session)

1. • CPT code 15771 is used for grafting of autologous fat harvested by liposuction technique.
   • The grafting is performed to specific areas: trunk, breasts, scalp, arms, and/or legs.
   • The code specifies an injectate volume of 50 cc or less.
2. Procedure Description:
   • This code is typically used for procedures where autologous fat grafting is performed using liposuction.
   • The harvested fat is then injected into specific areas of the body, including the trunk, breasts, scalp, arms, and/or legs.
   • The volume of the injectate is limited to 50 cc or less.
3. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Specify the use of the liposuction technique for fat harvesting, the specific areas where the fat is injected, and the volume of the injectate (50 cc or less). Document any specific conditions or complications.

Example:

Scenario: A patient desires cosmetic enhancement of the buttocks through fat grafting. Autologous fat is harvested from the thighs using liposuction, and 50 cc or less of the fat is injected into the buttocks.

Code Assignment:

• CPT Code: 15771
• Description: Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 ccs or less injectate.

Documentation: The medical record should include the following information:

• Use of liposuction technique for fat harvesting
• Specific areas where the fat is injected (e.g., buttocks)
• Volume of injectate (50 cc or less)
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the autologous fat grafting procedure described by CPT code 15771.

CPT CODE  ✚ 15772 Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs  each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure)
(Use 15772 in conjunction with 15771)

CPT CODE  15773 Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 ccs or less injectate
(Report 15773 only once per session)

1. • CPT code 15773 is used for grafting of autologous fat harvested by liposuction technique.
   • The grafting is performed on specific areas: face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet.
2. Procedure Description:
   • This code is typically used for procedures where autologous fat grafting is performed using liposuction.
   • The harvested fat is then injected into specific areas of the body, including the face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet.
3. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Specify the use of the liposuction technique for fat harvesting, the specific areas where the fat is injected, and any specific conditions or complications.

Example:

Scenario: A patient seeks cosmetic enhancement of facial features. Autologous fat is harvested from the thighs using liposuction, and the fat is then injected into various facial areas, including the face, eyelids, mouth, and neck.

Code Assignment:

• CPT Code: 15773
• Description: Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet.

Documentation: The medical record should include the following information:

• Use of liposuction technique for fat harvesting
• Specific areas where the fat is injected (e.g., face, eyelids, mouth, neck)
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the autologous fat grafting procedure described by CPT code 15773

 

CPT CODE  ✚ 15774 Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet;  each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure)
(Use 15774 in conjunction with 15773)
(Do not report 15769, 15771, 15772, 15773, 15774 in conjunction with 15876, 15877, 15878, 15879, 0232T, 0481T, 0489T, 0490T)
(For injection[s], autologous white blood cell concentrate [autologous protein solution], any site, including image guidance, harvesting, and preparation, when performed, use 0481T)

CPT CODE  15775 Punch graft for hair transplant; 1 to 15 punch grafts

1. • CPT code 15775 is used for punch grafts in the context of a hair transplant procedure.
   • The code covers the placement of 1 to 15-punch grafts.
2. Procedure Description:
   • This code is typically used for hair transplant procedures where small punch grafts are harvested from a donor site and transplanted into the recipient site (bald or thinning area).
3. Punch Grafts:
   • The term “punch graft” refers to a small circular section of tissue, often containing hair follicles, that is harvested and transplanted.
4. Several Punch Grafts:
   • The code specifies that it covers the placement of 1 to 15 punch grafts.
5. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Specify the number of punch grafts performed, the donor site, the recipient site, and any specific conditions or complications.

Example:

Scenario: A patient undergoes a hair transplant procedure to address male pattern baldness. Fifteen punch grafts, each containing hair follicles, are harvested from the back of the scalp and transplanted into the frontal hairline.

Code Assignment:

• CPT Code: 15775
• Description: Punch graft for hair transplant; 1 to 15 punch grafts.

Documentation: The medical record should include the following information:

• Number of punch grafts performed (15)
• Donor site (back of the scalp)
• Recipient site (frontal hairline)
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the punch grafts in a hair transplant procedure described by CPT code 15775

 

CPT CODE  15776 Punch graft for hair transplant more than 15 punch grafts
(For strip transplant, use 15220)

CPT CODE   ✚ 15777 Implantation of the biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk)
(List separately in addition to code for primary procedure)

(For implantation of biological implants for soft tissue reinforcement in tissues other than the breast and trunk, use 17999)
(For bilateral breast procedure, report 15777 twice. Do not report modifier 50 in conjunction with 15777)
(For implantation of mesh or other prosthesis for open incisional or ventral hernia repair, use 49568 in conjunction with 49560-49566)
(For insertion of mesh or other prosthesis for closure of a necrotizing soft tissue infection wound, use 49568 in conjunction with 11004-11006)
(For topical application of skin substitute graft to a wound surface, see 15271-15278)
(For repair of anorectal fistula with plug (eg, porcine small intestine submucosa [SIS]), use 46707)
(For insertion of mesh or other prosthesis for repair of pelvic floor defect, use 57267)
(For implantation of non-biologic or synthetic implant for fascial reinforcement of the abdominal wall, use 0437T)
(The supply of biologic implants should be reported separately in conjunction with 15777)

 

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