January 1997 Bulletin

11 new microsurgical codes in 1997 CPT
Generic code 15755 replaced by 4 families of codes

By Daniel J. Nagle, MD

Eleven new microsurgical codes have been added to the 1997 CPT nomenclature. The generic code 15755, Free flap (microvascular transfer), has been eliminated and replaced with these codes. These codes were developed through the efforts of the American Society for Reconstructive Microsurgery, the American Society for Surgery of the Hand, the American Society of Plastic and Reconstructive Surgeons, the American Academy of Otolaryngologists-Head and Neck Surgeons and the Academy.

The new codes have been divided into families. The first family contains the codes dealing with the free tissue transfer of skin, muscle and fascia. The second family of new codes has to do with free microvascular transfer of bone. The third family has codes dealing with toe-to-hand transfer and free toe joint transfer. Finally, the fourth family deals with free omental and free jejunal transfer.

The new skin, muscle and fascia codes are as follows:

15756 Free muscle flap with or without skin graft with microvascular anastomosis

15757 Free skin flap with microvascular anastomosis

15758 Free fascial flap with microvascular anastomosis

The combination of the free myofascial flap with the myocutaneous flap was thought to be appropriate because a survey of microsurgeons revealed the amount of work involved with these two procedures was not significantly different.

The work included in these procedures is the harvesting of the flap including flap dissection and microdissection of the vessels, the transfer of the flap and insetting of the flap, and the microanastomoses of one artery and two veins. If more vascular anastomoses are needed or if vein grafts are needed they would be coded separately. The direct closure of the donor site also is included.

What is not included is the preparation of the recipient site including the debridement. This can include the standard debridement codes 11040 to 11044 and also the new open fracture debridement codes 11010 to 11012 if one is dealing with an open fracture. Should the donor site require a skin graft for closure, that would be coded separately as 15100 or a variation of that code. The inclusion of nerve tissue in the transfer such as in an innervated gracilis or serratus transfer would necessitate the use of additional codes such as 64830 for microdissection of both the recipient and donor nerves and also microsurgical repair using one of the codes in the family 64831 to 64865. In a similar fashion, the inclusion of tendons for the reanimation of a hand, for example, would dictate the use of a code such as 26483, in addition to the microsurgical code.

In the case of a fasciocutaneous free flap that is combined with a bone graft, the code 15757 would not be used, but rather the osteocutaneous microsurgical codes in the family 20970 through 20972 would be used. If bone is harvested along with a myofascial flap or a fascial flap without overlying skin, the code 20902, that is a bone graft code, would be used in addition to 15756 or 15758, depending upon the tissue that is transferred.

The use of a split-thickness skin graft to cover a muscle flap is coded separately (15100) in the case of 15756 if a muscle flap (without skin) is being transferred. The same is true if a free fascial flap, 15758, is being transferred and requires a split-thickness skin graft for coverage. The rationale behind this is that many microsurgeons do not place the split-thickness skin graft on the transferred muscle until several days after the initial procedure. In the case of the free fascial flap, not all fascial flaps require a split-thickness skin graft, i.e., when the flap is used to fill a dead space beneath intact skin.

Two new codes were added to the free bone transfers. These were meant to complete the free bone transfer codes and to create parallelism between the codes that deal with transfer of bone without skin with those codes describing transfer of bone with skin. The new codes are:

20956 Bone graft with microvascular anastomosis; iliac crest

20957 metatarsal

These two codes were missing in this section, but were already included in the section of microvascular transfer of bone with skin, that is, the osteocutaneous flaps. In both the osteocutaneous free flap section as well as the section of bone graft with microvascular anastomosis without skin, you will notice the rib codes have been deleted. It was the consensus of the microsurgeons who were surveyed that the free rib transfer is no longer performed and should be eliminated from the nomenclature.

Four new codes were added to describe the transfer of toes to hand. There also were editorial changes. The following codes were eliminated because they refer to procedures that are no longer done: 26552, Reconstruction - thumb with toe; 26557, Toe to finger transfer; first state; 26558, each delay; and 26559, second stage.

While 20973 free osteocutaneous flap with microvascular anastomosis; great toe with web space, has remained behind with the other free osteocutaneous flaps, the new toe-to-hand codes were placed in the 26000 series of codes. These codes are relatively self-explanatory.

20973 Free osteocutaneous flap with microvascular anastomosis; great toe with space

26551 Toe-to-hand transfer with microvascular anastomosis; great toe "wrap-around" with bone graft

26553 other than great toe, single

26554 other than great toe, double

26556 Free toe joint transfer with microvascular anastomosis

The toe-to-hand transfers include the following work:

What is not included is:

One question that has been raised is whether or not there is a code for the microdissection of recipient vessels. Currently, there is no such code. We are currently working with the AMA CPT Editorial Panel to see whether or not one of the existing vascular codes could be used for this and if this proves to not be the case, a new code will have to be developed.

Finally, the last two codes to be created were the free omental and free jejunal codes.

49006 Free omental flap with microvascular anastomosis

43496 Free jejunum transfer with microvascular anastomosis

These codes were created to complete the new codes. Because of the significant variability in the amount of physician work involved in these cases, it was impossible to assign relative values to these procedures during the Relative Value Update Committee meeting. Therefore, the reimbursement for these procedures will be "by report."

Microvascular surgery codes

Free flap grafts (microvascular transfer)

15755 Free flap (microvascular transfer). Deleted.
To report, see 15756-15758
15756 Free muscle flap with or without skin graft
with microvascular anastomosis
15757 Free skin flap with microvascular anastomosis
15758 Free fascial flap with microvascular anastomosis

Bone grafts (microvascular anastomosis)

20955 Bone graft with microvascular anastomosis; fibula
20956 iliac crest
20957 metatarsal
20960 (rib). Deleted. To report, see 20962
20962 other (bone graft specify deleted) than fibula, iliac crest, or metatarsal (added)

Osteocutaneous grafts (microvascular anastomosis)

20969 Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, (rib deleted), metatarsal, or great toe
20970 (Free osteocutaneous flap with microvascular
anastomosis deleted) iliac crest
20971 (rib). Deleted. To report, see 20969
20972 metatarsal
20973 great toe with web space (For great toe, wrap-around procedure, use 26551)

Toe-to-hand transfers (microvascular anastomosis)

26552 (Reconstruction thumb with toe). Deleted.
To report, see 20973 or 26551, 26553, 26554
26557 (toe to finger transfer; first stage); 26558 (each delay);
26559 (second stage). Deleted. To report see 20973 or 26551, 26553, 26554.
20973 Free osteocutaneous flap with microvascular anastomosis; great toe with web space
26551 Toe-to-hand transfer with microvascular anastomosis; great toe "wrap-around" with bone graft (For great toe with web space, use 20973)
26553 other than great toe, single
26554 other than great toe, double
26556 Free toe joint transfer with microvascular anastomosis

Digestive system free tissue transfers (microvascular anastomosis)

49006 Free omental flap with microvascular anastomosis
43496 Free jejunum transfer with microvascular anastomosis


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