How To Use CPT Code 15610

CPT code 15610 describes the procedure of delaying a flap or sectioning of a flap at the scalp, arms, or legs. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 15610?

CPT 15610 describes the procedure of delaying a flap or sectioning of a flap at the scalp, arms, or legs. This involves dividing a previously created pedicled flap from its base and completing the inset of the graft at the recipient site. The provider also repairs the remaining wound where the flap was pedicled.

2. Official Description

The official description of CPT code 15610 is: ‘Delay of flap or sectioning of flap (division and inset) at scalp, arms, or legs.’

3. Procedure

The procedure for CPT code 15610 involves the following steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider divides a previously created pedicled flap from its base at the donor site.
3. The remnant portion of the flap base is sutured back to the donor site.
4. The provider completes the inset of the graft at the recipient site of the scalp, arms, or legs.
5. Both the donor and recipient sites are closed in layers.

4. Qualifying circumstances

CPT 15610 is performed when there is a need to delay a flap or section a flap at the scalp, arms, or legs. This procedure is typically done during the 90-day global period of the initial skin graft procedure and is considered a staged or planned second surgery. It is important to add modifier 58, Staged or related procedure or service by the same physician, to CPT 15610 when reporting this procedure. If a skin graft or flap is necessary to close the donor site after division of the pedicle, that procedure may be reported separately.

5. When to use CPT code 15610

CPT code 15610 should be used when there is a need to delay a flap or section a flap at the scalp, arms, or legs. It is important to ensure that the procedure is performed during the appropriate global period and that the necessary documentation is provided to support the medical necessity of the procedure.

6. Documentation requirements

To support a claim for CPT 15610, the following documentation is required:

• Explanation of the need for delaying a flap or sectioning a flap
• Description of the specific flap being divided
• Date of the procedure
• Details of the procedure, including the steps taken
• Documentation of any additional procedures performed, such as skin grafting
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 15610, it is important to ensure that the procedure is performed according to the official description and that the necessary documentation is provided. Modifier 58 should be added to indicate that the procedure is a staged or related procedure. If additional procedures, such as skin grafting, are performed, they should be reported separately.

8. Historical information

CPT 15610 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Similar codes to CPT 15610

There are several similar codes to CPT 15610 that describe other flap procedures. These include:

• CPT 15570: Immediate flap or graft closure of open wound of scalp, arms, and/or legs; defect 10 sq cm or less
• CPT 15572: Immediate flap or graft closure of open wound of scalp, arms, and/or legs; defect 10.1 sq cm to 30 sq cm
• CPT 15574: Immediate flap or graft closure of open wound of scalp, arms, and/or legs; defect 30.1 sq cm to 60 sq cm
• CPT 15576: Immediate flap or graft closure of open wound of scalp, arms, and/or legs; defect over 60 sq cm
• CPT 15738: Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (eg, breast, trunk)

9. Examples

1. A patient undergoes a delayed flap procedure at the scalp to repair a large defect caused by trauma.
2. A pedicled flap is divided and inset at the leg to cover a chronic wound that has not responded to other treatments.
3. A previously created flap is sectioned and repositioned at the arm to improve the aesthetic appearance of a scar.
4. A patient with a scalp defect undergoes a delayed flap procedure to prepare for a subsequent hair transplant.
5. A pedicled flap is divided and inset at the leg to provide coverage for a bone graft procedure.
6. A delayed flap procedure is performed at the scalp to repair a defect resulting from the removal of a skin tumor.
7. A previously created flap is sectioned and repositioned at the arm to improve the function of a contracted joint.
8. A patient with a leg wound undergoes a delayed flap procedure to promote healing and prevent infection.
9. A pedicled flap is divided and inset at the scalp to cover an area of hair loss caused by a burn injury.
10. A delayed flap procedure is performed at the leg to reconstruct a defect resulting from the removal of a malignant tumor.