How To Use CPT Code 15841

CPT code 15841 describes the procedure for grafting a free muscle to restore a more normal appearance in patients suffering from facial nerve paralysis. 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 15841?

CPT 15841 is used to describe the procedure of grafting a free muscle to restore facial movement in patients with facial nerve paralysis. This code is used when a provider removes a piece of muscle tissue from another area of the body, such as the back, chest, abdomen, or thigh, and attaches it to the face to improve the patient’s appearance and functionality.

2. Official Description

The official description of CPT code 15841 is: ‘Graft for facial nerve paralysis free muscle graft (including obtaining graft).’ This code includes the removal of muscle tissue from a donor site and the transplantation of the muscle to the affected area of the face.

3. Procedure

The procedure for CPT code 15841 involves several steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider makes a horizontal or longitudinal incision to remove a piece of muscle tissue from a donor site, such as the gracilis, pectoralis minor, latissimus dorsi, rectus abdominis, rectus femoris, or extensor digitorum brevis.
3. The cut muscle is then transplanted to the affected area of the face.
4. The provider sutures the transplanted muscle in place to secure it.

4. Qualifying circumstances

CPT 15841 is used for patients with facial nerve paralysis, which results in the loss of movement in the face due to damage to the facial nerve. The procedure is performed to restore a more normal appearance and improve facial functionality. The patient must meet the criteria for facial nerve paralysis, and the provider must determine that grafting a free muscle is the appropriate treatment option.

5. When to use CPT code 15841

CPT code 15841 should be used when a provider performs the grafting procedure to restore facial movement in patients with facial nerve paralysis. It is important to ensure that the procedure meets the specific requirements outlined in the code description. If the procedure does not involve grafting a free muscle for facial nerve paralysis, a different CPT code should be used.

6. Documentation requirements

To support a claim for CPT code 15841, the provider must document the following information:

• Patient’s diagnosis of facial nerve paralysis
• Details of the procedure, including the specific muscle tissue used for grafting
• Date of the procedure
• Start and end time of the procedure
• Any additional relevant information, such as the size of the graft or any complications encountered
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 15841, ensure that the procedure meets the requirements outlined in the code description. It is important to accurately document the procedure and provide any necessary supporting documentation. CPT code 15841 should not be reported with other codes unless additional procedures were performed during the same session that are separately reportable.

8. Historical information

CPT code 15841 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with facial nerve paralysis undergoes a grafting procedure using the gracilis muscle to restore facial movement.
2. A provider performs a grafting procedure using the latissimus dorsi muscle to improve the appearance and functionality of a patient with facial nerve paralysis.
3. A patient with facial nerve paralysis undergoes a grafting procedure using the rectus abdominis muscle to restore facial movement.
4. A provider performs a grafting procedure using the rectus femoris muscle to improve the appearance and functionality of a patient with facial nerve paralysis.
5. A patient with facial nerve paralysis undergoes a grafting procedure using the extensor digitorum brevis muscle to restore facial movement.
6. A provider performs a grafting procedure using the pectoralis minor muscle to improve the appearance and functionality of a patient with facial nerve paralysis.
7. A patient with facial nerve paralysis undergoes a grafting procedure using the gracilis muscle to restore facial movement.
8. A provider performs a grafting procedure using the latissimus dorsi muscle to improve the appearance and functionality of a patient with facial nerve paralysis.
9. A patient with facial nerve paralysis undergoes a grafting procedure using the rectus abdominis muscle to restore facial movement.
10. A provider performs a grafting procedure using the rectus femoris muscle to improve the appearance and functionality of a patient with facial nerve paralysis.