How To Use CPT Code 15769

CPT 15769 refers to the grafting of autologous soft tissue, harvested by direct excision, and used to fill in a defect elsewhere on the patient’s body. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT code 15769.

1. What is CPT 15769?

CPT 15769 is a medical procedure code that describes the grafting of autologous soft tissue, such as fat, dermis, or fascia, harvested by direct excision from a donor site on the patient’s body and used to fill in a defect at a recipient site elsewhere on the same patient during the same operative session.

2. 15769 CPT code description

The official description of CPT code 15769 is: “Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)”.

3. Procedure

The 15769 procedure involves the following steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider incises the skin over the area of the donor site.
3. The incision is extended down through layers, depending on the nature and complexity of the graft, to obtain tissue such as dermis, fat, or fascia.
4. The provider dissects around the targeted tissue and frees it from surrounding tissues.
5. The dissected tissue graft is pulled away from surrounding tissue.
6. The graft is used to fill a defect at the recipient site elsewhere on the patient’s body.
7. The donor and recipient sites are closed with sutures.

4. Qualifying circumstances

Patients eligible to receive CPT code 15769 services are those who require autologous soft tissue grafting to fill in a defect on their body. This may include patients with congenital deformities, traumatic injuries, or those undergoing reconstructive surgery following tumor removal or other medical conditions that have resulted in tissue loss or damage.

5. When to use CPT code 15769

It is appropriate to bill the 15769 CPT code when the provider performs a grafting procedure using autologous soft tissue harvested by direct excision from a donor site on the patient’s body and used to fill in a defect at a recipient site elsewhere on the same patient during the same operative session.

6. Documentation requirements

Documentation supporting a claim for CPT 15769 should include:

• A detailed description of the patient’s medical condition requiring the grafting procedure.
• A clear explanation of the surgical plan, including the donor and recipient sites, the type of tissue harvested, and the method of grafting.
• Operative notes detailing the procedure, including the incision, dissection, harvesting, grafting, and closure of the donor and recipient sites.
• Postoperative care instructions and follow-up plans.

7. Billing guidelines

When billing for CPT code 15769, it is important to follow the appropriate guidelines and rules. This code is reported once per graft site. Be aware of similar codes and their specific usage, such as 15770 for composite dermis-fat-fascia grafts, 15771 and +15772 for liposuction harvesting and grafting of autologous fat to trunk, breasts, scalp, arms, and/or legs, and 15773 and +15774 for liposuction harvesting and grafting of autologous fat to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, or feet.

8. Historical information

CPT 15769 was added to the Current Procedural Terminology system on January 1, 2020. There have been no updates since its addition.

9. Similar codes to CPT 15769

Five similar codes to CPT 15769 and how they differentiate are:

• CPT 15770: Involves the harvesting and grafting of a composite dermis-fat-fascia graft.
• CPT 15771 and +15772: Used for liposuction harvesting and grafting of autologous fat to trunk, breasts, scalp, arms, and/or legs.
• CPT 15773 and +15774: Used for liposuction harvesting and grafting of autologous fat to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, or feet.

10. Examples

Here are 10 detailed examples of CPT code 15769 procedures:

1. Grafting of autologous fat harvested from the abdomen to fill a defect in the patient’s breast following tumor removal.
2. Using autologous dermis harvested from the thigh to repair a facial defect caused by a traumatic injury.
3. Grafting of autologous fascia harvested from the patient’s back to reconstruct a damaged tendon in the hand.
4. Harvesting autologous fat from the patient’s buttocks to fill a defect in the patient’s calf caused by a congenital deformity.
5. Using autologous dermis harvested from the patient’s arm to repair a defect in the patient’s scalp following tumor removal.
6. Grafting of autologous fascia harvested from the patient’s leg to repair a damaged ligament in the patient’s knee.
7. Harvesting autologous fat from the patient’s thigh to fill a defect in the patient’s cheek caused by a traumatic injury.
8. Using autologous dermis harvested from the patient’s back to repair a defect in the patient’s chest following tumor removal.
9. Grafting of autologous fascia harvested from the patient’s abdomen to reconstruct a damaged tendon in the patient’s foot.
10. Harvesting autologous fat from the patient’s hip to fill a defect in the patient’s chin caused by a congenital deformity.