15570* Formation of direct or tubed pedicle, with or without transfer; trunk
15731* Forehead flap with preservation of vascular pedicle (e.g., axial pattern flap, paramedian forehead flap)
15732* Muscle, myocutaneous, or fasciocutaneous flap; head and neck (e.g., temporalis, masseter muscle, sternocleidomastoid, levator scapulae)
15734* Muscle, myocutaneous, or fasciocutaneous flap; trunk
15736* Muscle, myocutaneous, or fasciocutaneous flap; upper extremity
15738* Muscle, myocutaneous, or fasciocutaneous flap; lower extremity
15740* Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel
15756* Free muscle or myocutaneous flap with microvascular anastomosis
DEFINITIONS
Congenital Anomaly: A physical developmental defect that is present at the time of birth, and that is identified within the first twelve months of birth. Cosmetic Surgery: Defined by the American Society of Plastic Surgeons, “is performed to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem.” Functional/Physical Impairment: A physical/functional or physiological impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas:
physical and motor tasks; independent movement; performing basic life functions.
Injury: Bodily damage other than Sickness, including all related conditions and recurrent symptoms.
Microtia: The most complex congenital ear deformity when the outer ear appears as either a sausage-shaped structure resembling little more than the earlobe. It may or may not be missing the external auditory or hearing canal. Hearing is impaired to varying degrees.
Reconstructive Surgery: Defined by the American Society of Plastic Surgeons, “is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.”
Sickness: Physical illness, disease or Pregnancy. The term Sickness as used in this Certificate does not include mental illness or substance abuse, regardless of the cause or origin of the mental illness or substance abuse.
Coding Clarification
** Flaps (Skin and/or Deep Tissues) Procedures: 15570-15738
o The regions listed refer to a donor site when a tube is formed for later transfer or when a “delay” of flap occurs prior to the transfer. Codes 15732-15738 are described by donor site of the muscle, myocutaneous, or fasciocutaneous flap.
o A repair of a donor site requiring a skin graft or local flaps is considered an additional separate procedure.
o (For microvascular flaps, see 15756-15758)
o (For flaps without inclusion of a vascular pedicle, see 15570-15576)
o (For adjacent tissue transfer flaps, see 14000-14302)
o The regions listed refer to the recipient area (not the donor site) when a flap is being attached in a transfer or to a final site.
o Codes 15570-15738 do not include extensive immobilization (e.g., large plaster casts and other immobilizing devices are considered additional separate procedures).
** Other Flaps and Grafts Procedures: 15740-15777
o 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 (e.g., thumb). Repair of donor site requiring skin graft or local flaps should be reported as an additional procedure.
o 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.
o 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.
