How To Use CPT Code 15733

CPT code 15733 describes the procedure of creating a muscle, myocutaneous, or fasciocutaneous flap from specific muscles in the head and neck region to cover a nearby defect. 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 15733?

CPT code 15733 is used to describe the creation of a muscle, myocutaneous, or fasciocutaneous flap from specific muscles in the head and neck region. This flap is then used to cover a nearby defect, providing reconstruction or repair to the affected area. The procedure involves preserving the vascular supply of the flap, ensuring its viability and successful integration into the recipient site.

2. Official Description

The official description of CPT code 15733 is: ‘Muscle, myocutaneous, or fasciocutaneous flap head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae).’ This code specifically applies to the creation of flaps using muscles in the head and neck region, preserving their vascular pedicle.

3. Procedure

1. The patient is placed under general anesthesia to ensure comfort and minimize pain during the procedure.
2. The physician prepares both the donor site (where the flap will be taken from) and the recipient site (where the flap will be placed).
3. Using a sharp knife, the provider carefully lifts a flap of muscle, myocutaneous tissue (muscle and skin), or fasciocutaneous tissue (skin, subcutaneous tissue, and underlying fascia) from one of the specific muscles in the head and neck region.
4. The flap is rotated to cover the nearby defect, ensuring proper alignment and integration with the recipient site.
5. The donor site (secondary defect) and the recipient site (primary defect) are closed using sutures, and dressings are applied to both sites to promote healing and prevent infection.

4. Qualifying circumstances

CPT code 15733 is used when a muscle, myocutaneous, or fasciocutaneous flap is created from specific muscles in the head and neck region to cover a nearby defect. The procedure requires the preservation of the named vascular pedicle, which ensures the viability of the flap. This code is applicable when the patient’s condition necessitates the use of such a flap for reconstruction or repair.

5. When to use CPT code 15733

CPT code 15733 should be used when a muscle, myocutaneous, or fasciocutaneous flap is created from the specified muscles in the head and neck region to cover a nearby defect. This code is appropriate when the procedure involves the preservation of the named vascular pedicle. It is important to accurately document the specific muscles used and the nature of the defect being addressed to support the use of this code.

6. Documentation requirements

To support a claim for CPT code 15733, the following documentation is required:

• Clear indication of the need for the procedure and the specific defect being addressed
• Description of the muscles used to create the flap
• Documentation of the preservation of the named vascular pedicle
• Date of the procedure
• Details of the donor and recipient sites
• Method of closure for both the donor and recipient sites
• Any additional relevant information or complications encountered during the procedure

7. Billing guidelines

When billing for CPT code 15733, it is important to ensure that the procedure involves the creation of a muscle, myocutaneous, or fasciocutaneous flap from the specified muscles in the head and neck region. The preservation of the named vascular pedicle is also crucial. There are no specific guidelines regarding reporting this code with other codes, but it is essential to accurately document the procedure and provide any necessary supporting documentation.

8. Historical information

CPT code 15733 was added to the Current Procedural Terminology system on January 1, 2018. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with a large facial defect resulting from trauma undergoes a muscle flap procedure using the temporalis muscle to provide reconstruction.
2. A patient with a defect in the neck region due to tumor resection undergoes a myocutaneous flap procedure using the sternocleidomastoid muscle for repair.
3. A patient with a complex defect in the buccal region undergoes a fasciocutaneous flap procedure using the buccinators muscle to restore the affected area.
4. A patient with a defect in the jaw region due to previous surgery undergoes a muscle flap procedure using the masseter muscle for reconstruction.
5. A patient with a defect in the neck region undergoes a myocutaneous flap procedure using the levator scapulae muscle to provide repair and reconstruction.
6. A patient with a complex defect in the head region undergoes a fasciocutaneous flap procedure using the genioglossus muscle for reconstruction.
7. A patient with a defect in the cheek region undergoes a muscle flap procedure using the buccinators muscle to restore the affected area.
8. A patient with a defect in the neck region undergoes a myocutaneous flap procedure using the sternocleidomastoid muscle for repair.
9. A patient with a complex defect in the jaw region undergoes a fasciocutaneous flap procedure using the temporalis muscle to provide reconstruction.