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Official Description

Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae)

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 15733 involves the use of a muscle, myocutaneous, or fasciocutaneous flap specifically for reconstructive purposes in the head and neck region. This technique is employed to repair defects that may arise due to trauma, surgical excision, or congenital anomalies. The flap is created from a donor site, which is a specific area of the body where the tissue is harvested. The harvested tissue includes muscle, skin, or a combination of both, and is carefully prepared to maintain its blood supply through a named vascular pedicle. This vascular pedicle is crucial as it ensures that the flap remains viable after being rotated into position to cover the defect. Once the flap is in place, it is sutured securely to the surrounding tissue, and the donor site is subsequently closed, either with sutures or, if necessary, a skin graft. It is important to note that if a skin graft is required to close the donor site, this procedure should be reported separately. This code is specifically designated for flaps taken from the head and neck regions, utilizing named vascular pedicles such as the buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, and levator scapulae.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure associated with CPT® Code 15733 is indicated for various conditions that necessitate the reconstruction of defects in the head and neck area. These indications may include:

  • Trauma: Injuries resulting in significant tissue loss or damage in the head and neck region.
  • Oncological Excision: Surgical removal of tumors or cancerous lesions that leave a defect requiring reconstruction.
  • Congenital Anomalies: Birth defects that result in structural abnormalities in the head and neck that may require surgical correction.
  • Infection: Severe infections that lead to tissue necrosis or loss, necessitating reconstruction to restore function and appearance.

2. Procedure

The procedure for CPT® Code 15733 involves several critical steps to ensure successful reconstruction of the defect in the head and neck area. These steps include:

  • Step 1: Donor Site Selection The surgeon identifies an appropriate donor site on the head or neck from which to harvest the muscle, myocutaneous, or fasciocutaneous flap. The selection is based on the vascular supply and the type of tissue needed for the reconstruction.
  • Step 2: Flap Preparation Once the donor site is selected, the surgeon carefully dissects the tissue while preserving the vascular pedicle. This step is crucial to maintain blood flow to the flap, ensuring its viability once repositioned.
  • Step 3: Flap Rotation After the flap is prepared, it is rotated into position to cover the defect. The rotation must be done with precision to ensure that the flap fits well and adequately covers the area needing reconstruction.
  • Step 4: Suturing the Flap The flap is then sutured into place, securing it to the surrounding tissue. This step is vital for the integration of the flap with the recipient site.
  • Step 5: Donor Site Closure Finally, the donor site is closed using sutures or, if necessary, a skin graft. If a skin graft is required, this procedure must be reported separately, as it is not included in the CPT® Code 15733.

3. Post-Procedure

Post-procedure care for patients undergoing the flap reconstruction using CPT® Code 15733 includes monitoring the viability of the flap, managing pain, and preventing infection. Patients are typically advised to keep the surgical area clean and dry, and to follow specific instructions regarding activity restrictions to promote healing. Follow-up appointments are essential to assess the healing process and to address any complications that may arise, such as flap failure or infection. The recovery period may vary depending on the extent of the procedure and the individual patient's health status.

Short Descr MUSC MYOQ/FSCQ FLP H&N PEDCL
Medium Descr MUSC MYOQ/FSCQ FLAP HEAD&NECK W/NAMED VASC PEDCL
Long Descr Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae)
Status Code Active Code
Global Days 090 - Major Surgery
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 1 - Co-surgeons could be paid, though supporting documentation is required...
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Procedure or Service, Multiple Reduction Applies
ASC Payment Indicator Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) none
MUE 2
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
GC This service has been performed in part by a resident under the direction of a teaching physician
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
RT Right side (used to identify procedures performed on the right side of the body)
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
SG Ambulatory surgical center (asc) facility service
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
53 Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
54 Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.
55 Postoperative management only: when 1 physician or other qualified health care professional performed the postoperative management and another performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure number.
62 Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
77 Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
82 Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CR Catastrophe/disaster related
E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
ET Emergency services
GA Waiver of liability statement issued as required by payer policy, individual case
GJ "opt out" physician or practitioner emergency or urgent service
GW Service not related to the hospice patient's terminal condition
GZ Item or service expected to be denied as not reasonable and necessary
LT Left side (used to identify procedures performed on the left side of the body)
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
Action
Notes
2018-01-01 Added Code Added.
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Description
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Description
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