How To Use CPT Code 15731

CPT code 15731 describes the creation of a flap of skin from the forehead to treat injuries or open wounds on the face or scalp. 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 15731?

CPT 15731 is used to describe the procedure in which a flap of skin is created from the forehead to treat injuries or open wounds on the face or scalp. The flap, along with its vascular supply, is rotated to cover the affected area, ensuring proper healing and restoration of the damaged tissue.

2. Official Description

The official description of CPT code 15731 is: ‘Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap).’ This code specifically refers to the creation of a flap from the forehead, preserving its vascular pedicle, to treat injuries or open wounds on the face or scalp.

3. Procedure

The procedure for CPT code 15731 involves several steps:

1. The provider assesses the size and location of the injury or open wound on the face or scalp.
2. The provider determines the appropriate size of the flap required from the forehead as a donor site.
3. The provider identifies the blood vessels, such as the supratrochlear vessels, using ultrasound to ensure the flap retains its connection to its blood supply.
4. The provider excises the flap from the forehead, ensuring that it still retains its connection to its blood supply.
5. The provider rotates the flap to cover the affected area on the face or scalp and secures it in place with sutures.
6. The provider closes the donor area on the forehead.

4. Qualifying circumstances

CPT 15731 is used for patients who require the creation of a forehead flap to treat injuries or open wounds on the face or scalp. The procedure is typically performed by a qualified healthcare professional who has the necessary expertise in flap reconstruction. The patient must have a specific need for this procedure, as determined by the provider, and meet any additional criteria set by the payer or insurance company.

5. When to use CPT code 15731

CPT code 15731 should be used when a provider performs the procedure to create a forehead flap with preservation of the vascular pedicle. This code is appropriate for cases where the flap is used to treat injuries or open wounds on the face or scalp. It is important to ensure that the procedure meets the specific requirements outlined in the code description.

6. Documentation requirements

To support a claim for CPT 15731, the provider must document the following information:

• Patient’s diagnosis or condition necessitating the use of a forehead flap
• Size and location of the injury or open wound on the face or scalp
• Details of the flap creation, including the size and location of the flap on the forehead
• Identification of the blood vessels used to preserve the vascular pedicle
• Description of the rotation and placement of the flap to cover the affected area
• Method of securing the flap in place
• Closure of the donor area on the forehead
• Any additional relevant information or complications encountered during the procedure

7. Billing guidelines

When billing for CPT 15731, it is important to ensure that the procedure meets the specific requirements outlined in the code description. The provider should also follow any additional guidelines set by the payer or insurance company. It is important to accurately report the procedure and any associated services or supplies provided during the same encounter.

8. Historical information

CPT code 15731 was added to the Current Procedural Terminology system on January 1, 2007. There have been no updates or changes to the code since its addition.

9. Examples

1. A plastic surgeon creating a forehead flap to treat a large facial defect caused by trauma.
2. A dermatologist using a forehead flap to reconstruct a scalp defect resulting from the removal of a skin cancer lesion.
3. An otolaryngologist performing a forehead flap procedure to repair a nasal defect following the removal of a tumor.
4. A reconstructive surgeon using a forehead flap to treat a scalp defect caused by burns.
5. A maxillofacial surgeon performing a forehead flap procedure to reconstruct a jaw defect resulting from trauma.
6. A craniofacial surgeon using a forehead flap to repair a cranial defect caused by a congenital anomaly.
7. A plastic surgeon creating a forehead flap to treat a scalp defect resulting from a previous surgical procedure.
8. An oculoplastic surgeon using a forehead flap to reconstruct an eyelid defect caused by trauma.
9. A facial plastic surgeon performing a forehead flap procedure to repair a facial defect resulting from the removal of a skin lesion.
10. A reconstructive surgeon using a forehead flap to treat a scalp defect caused by a previous injury.