How To Use CPT Code 15757

CPT code 15757 describes the procedure of creating a free skin flap with microvascular anastomosis. 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 15757?

CPT 15757 is a code used to describe the procedure of creating a free skin flap with microvascular anastomosis. This involves the use of microvascular techniques to create a flap of skin taken from a donor site and place it at the wound site. The blood vessels in the flap are then connected to the vessels at the wound site under microscopic guidance.

2. Official Description

The official description of CPT code 15757 is: ‘Free skin flap with microvascular anastomosis.’

3. Procedure

The procedure for CPT code 15757 involves several steps:

1. The physician administers general anesthesia to the patient.
2. The physician prepares both the donor site and the recipient site.
3. A skin flap is excised from the donor site.
4. The flap is then placed at the recipient site.
5. The blood vessels in the flap are connected to the vessels at the recipient site under microscopic guidance.
6. The repaired site is checked for any leakages by injecting dye.
7. If necessary, repairs are made to the vessel connections and the flap is secured with sutures.
8. The skin of both the donor and recipient sites are closed with sutures, and a dressing is applied to both sites.

4. Qualifying circumstances

CPT code 15757 is used for patients who require a free skin flap with microvascular anastomosis. This procedure is typically performed for patients who need reconstruction or repair of a wound. The physician must use microvascular techniques to connect the blood vessels in the flap to the vessels at the wound site.

5. When to use CPT code 15757

CPT code 15757 should be used when a physician performs a free skin flap procedure with microvascular anastomosis. This code is specific to cases where microvascular techniques are used to connect the blood vessels in the flap to the vessels at the wound site. It should not be used for other types of flap procedures or when microvascular anastomosis is not performed.

6. Documentation requirements

To support a claim for CPT code 15757, the physician must document the following information:

• Patient’s diagnosis and the need for the free skin flap procedure
• Details of the procedure, including the specific techniques used for microvascular anastomosis
• Date of the procedure
• Start and end time of the procedure
• Any repairs made to the vessel connections
• Details of the closure of the donor and recipient sites
• Signature of the performing physician

7. Billing guidelines

When billing for CPT code 15757, ensure that the procedure performed meets the requirements of a free skin flap with microvascular anastomosis. Do not report code 69990 in addition to code 15757. Follow the appropriate coding guidelines and modifiers as required by the payer.

8. Historical information

CPT code 15757 was added to the Current Procedural Terminology system on January 1, 1997. It was later added to the Inpatient Only (IPO) list for Medicare in 2017.

9. Examples

1. A plastic surgeon performing a free skin flap with microvascular anastomosis to reconstruct a breast after mastectomy.
2. A reconstructive surgeon using microvascular techniques to create a free skin flap for wound repair in a patient with extensive trauma.
3. A maxillofacial surgeon performing a free skin flap with microvascular anastomosis to reconstruct a defect in the jaw.
4. A burn surgeon using microvascular techniques to create a free skin flap for wound coverage in a patient with severe burns.
5. A hand surgeon performing a free skin flap with microvascular anastomosis to reconstruct a finger after traumatic amputation.
6. A plastic surgeon using microvascular techniques to create a free skin flap for breast reconstruction in a patient undergoing a mastectomy.
7. A reconstructive surgeon performing a free skin flap with microvascular anastomosis to repair a large wound in a patient with cancer.
8. A craniofacial surgeon using microvascular techniques to create a free skin flap for facial reconstruction in a patient with congenital deformities.
9. A vascular surgeon performing a free skin flap with microvascular anastomosis to restore blood flow to a limb after a severe injury.
10. A reconstructive surgeon using microvascular techniques to create a free skin flap for wound closure in a patient with a chronic non-healing ulcer.