How To Use CPT Code 15738

CPT code 15738 describes the creation of a muscle, myocutaneous, or fasciocutaneous flap from a lower extremity to treat injury or open wounds on an affected area. 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 15738?

CPT code 15738 is used to describe the procedure of creating a muscle, myocutaneous, or fasciocutaneous flap from a lower extremity to treat injury or open wounds on an affected area. This code is used when a healthcare provider prepares the donor site on the patient’s lower extremity and the affected recipient site, creates a flap from the lower extremity donor site, and places the flap at the site of repair. The provider ensures that the blood vessels of the flap are intact and may need to tunnel the flap under the skin to reach the recipient site. The provider then closes the skin of the donor and recipient sites with sutures and applies dressing to both sites.

2. Official Description

The official description of CPT code 15738 is: ‘Muscle, myocutaneous, or fasciocutaneous flap lower extremity.’

3. Procedure

When performing CPT code 15738, the healthcare provider follows a specific procedure:

1. The patient is appropriately prepped and anesthetized.
2. The provider prepares the donor site on the patient’s lower extremity and the affected recipient site with the primary defect.
3. A muscle, myocutaneous, or fasciocutaneous flap is created from the lower extremity donor site.
4. The flap is placed at the site of repair, ensuring that the blood vessels of the flap are intact.
5. If necessary, the provider may tunnel the flap under the skin to reach the recipient site.
6. The provider closes the skin of the donor and recipient sites with sutures.
7. Dressings are applied to both the donor and recipient sites.

4. Qualifying circumstances

CPT code 15738 is used when a muscle, myocutaneous, or fasciocutaneous flap is created from a lower extremity to treat injury or open wounds on an affected area. The procedure is performed on patients who require this specific type of flap for repair or reconstruction. The provider must ensure that the blood vessels of the flap are intact and may need to tunnel the flap under the skin to reach the recipient site. The primary defect is the site that needs to be repaired or reconstructed, while the secondary defect refers to the defect at the donor site.

5. When to use CPT code 15738

CPT code 15738 should be used when a healthcare provider creates a muscle, myocutaneous, or fasciocutaneous flap from a lower extremity to treat injury or open wounds on an affected area. This code is appropriate when the specific procedure described in the official description is performed. It is important to accurately document the details of the procedure to support the use of this code.

6. Documentation requirements

To support a claim for CPT code 15738, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for the muscle, myocutaneous, or fasciocutaneous flap
• Details of the procedure, including the specific flap created and the donor and recipient sites
• Date of the procedure
• Start and end time of the procedure
• Any additional details or complications encountered during the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 15738, ensure that the procedure described in the official description is performed. It is important to accurately document the details of the procedure to support the use of this code. There are no specific billing guidelines or modifiers mentioned for this code.

8. Historical information

CPT code 15738 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A patient with a severe leg injury undergoes a muscle flap procedure using CPT code 15738 to repair the affected area.
2. A healthcare provider performs a myocutaneous flap procedure on a patient with a chronic wound using CPT code 15738.
3. A patient with a traumatic injury to the lower extremity undergoes a fasciocutaneous flap procedure using CPT code 15738 for wound repair.
4. A healthcare provider performs a muscle flap procedure on a patient with a large open wound on the leg using CPT code 15738.
5. A patient with a non-healing wound on the lower extremity undergoes a myocutaneous flap procedure using CPT code 15738 for wound closure.