CPT CODING: MICROSURGICAL SCALP RECONSTRUCTION IN THE ELDERLY: A SYSTEMATIC REVIEW AND POOLED ANALYSIS OF THE CURRENT DATA

by Raymund Janevicius, MD

Enjoy a free coding perspective from the March 2015 PRS article “Microsurgical Scalp Reconstruction in the Elderly: A Systematic Review and Pooled Analysis of the Current Data

CODING PERSPECTIVE:

15756              Free muscle or myocutaneous flap with microvascular anastomosis

15757              Free skin flap with microvascular anastomosis

15758              Free fascial flap with microvascular anastomosis

49906              Free omental flap with microvascular anastomosis

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  • The free flap codes are not donor site specific.  All free muscle flaps are reported with code 15756.  Thus, a free rectus abdominis flap and a free latissimus dorsi flap are each reported with code 15756.
  • Both free muscle and free myocutaneous flaps are reported with code 15757.
  • All free skin flaps are coded with CPT code 15757.
  • Free flap codes are global and include:
    • Harvest of the free flap
    • Direct closure of the donor site
    • Dissection of recipient vessels
    • Microvascular anastomosis of one artery and two veins
    • Inset of the flap
    • Monitoring of the flap intra-operatively and post-operatively
  • If other procedures are performed to reconstruct the scalp defect, they are separately reported.  A split thickness skin graft to cover a muscle flap is reported with codes 15120 and 15121, based upon the size of the skin graft.
  • The primary ablative procedures are coded separately, in addition to the free flap codes.

For a list of all articles with CPT coding visit the CPT Coding Collection on the Residents’ Gateway Homepage.

REFERENCES

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Microsurgical Scalp Reconstruction in the Elderly: A Systematic Review and Pooled Analysis of the Current Data
Sosin, Michael M.D.; Schultz, Benjamin D. B.A.; De La Cruz, Carla B.S.; Hammond, Edward R. M.D., M.P.H., Ph.D.; Christy, Michael R. M.D.; Bojovic, Branko M.D.; Rodriguez, Eduardo D. M.D., D.D.S.
Plastic & Reconstructive Surgery: March 2015 – Volume 135 – Issue 3 – p 856–866 doi: 10.1097/PRS.0000000000000959

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