How To Use CPT Code 15845

CPT code 15845 describes a procedure in which a qualified healthcare provider transfers muscle tissue from one area of the head or face to a part of the face affected by 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 15845?

CPT 15845 is a code used to describe a procedure in which a qualified healthcare provider transfers muscle tissue from one area of the head or face to a part of the face affected by facial nerve paralysis. This procedure aims to restore a more normal appearance to the face by rotating the grafted muscle into place without impacting the nerve and vascular supply in the transferred muscle.

2. Official Description

The official description of CPT code 15845 is: ‘Graft for facial nerve paralysis regional muscle transfer.’

3. Procedure

During the procedure, the healthcare provider partially excises a portion of muscle tissue from the temporalis, masseter, or digastric muscles in the head. The muscle tissue is then transferred by rotating it to the affected area of the face and suturing it into place. This technique aims to restore movement and symmetry to the face in patients with facial nerve paralysis.

4. Qualifying circumstances

CPT 15845 is typically performed on patients who have facial nerve paralysis, which results in the loss of movement in the face due to damage of the facial nerve. The procedure is intended to repair or replace defective or missing tissue or structure with another material, such as muscle tissue harvested from the temporalis, masseter, or digastric muscles. The patient must meet the criteria for facial nerve paralysis and be under the care of a qualified healthcare provider who is trained in performing this specific procedure.

5. When to use CPT code 15845

CPT code 15845 should be used when a qualified healthcare provider performs a regional muscle transfer to address facial nerve paralysis. This code is specific to the grafting procedure described and should be used when the provider rotates the grafted muscle into place without impacting the nerve and vascular supply in the transferred muscle.

6. Documentation requirements

To support a claim for CPT code 15845, the healthcare provider must document the following information:

• Patient’s diagnosis of facial nerve paralysis
• Details of the muscle tissue excised and transferred
• Date of the procedure
• Specific technique used for the regional muscle transfer
• Any additional procedures performed in conjunction with the muscle transfer
• Signature of the qualified healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 15845, ensure that the procedure meets the criteria outlined in the official description. It is important to accurately document the details of the procedure and any additional services provided. Additionally, be aware of any specific guidelines or requirements from insurance providers regarding the use of this code.

8. Historical information

CPT code 15845 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. Similar codes to CPT 15845

There are several similar codes to CPT 15845 that may be used in different circumstances. These include:

• CPT 15846: Graft for facial nerve paralysis, temporalis muscle transfer
• CPT 15847: Graft for facial nerve paralysis, masseter muscle transfer
• CPT 15848: Graft for facial nerve paralysis, digastric muscle transfer
• CPT 15780: Implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement (e.g., breast, trunk)
• CPT 15879: Other repair (closure) procedures on the integumentary system

9. Examples

1. A qualified healthcare provider performing a muscle transfer from the temporalis muscle to address facial nerve paralysis in a patient.
2. A patient with facial nerve paralysis undergoing a muscle transfer procedure using the masseter muscle.
3. A healthcare provider performing a digastric muscle transfer to restore movement and symmetry in a patient with facial nerve paralysis.
4. A regional muscle transfer procedure being performed on a patient with facial nerve paralysis using muscle tissue from the temporalis muscle.
5. A qualified healthcare provider performing a muscle transfer procedure on a patient with facial nerve paralysis using muscle tissue from the masseter muscle.
6. A patient with facial nerve paralysis undergoing a muscle transfer procedure using the digastric muscle to restore movement and symmetry to the face.
7. A healthcare provider performing a muscle transfer procedure on a patient with facial nerve paralysis using muscle tissue from the temporalis muscle.
8. A regional muscle transfer being performed on a patient with facial nerve paralysis using muscle tissue from the masseter muscle.
9. A qualified healthcare provider performing a muscle transfer procedure on a patient with facial nerve paralysis using muscle tissue from the digastric muscle.
10. A patient with facial nerve paralysis undergoing a muscle transfer procedure using muscle tissue from the temporalis muscle to restore movement and symmetry to the face.