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The procedure described by CPT® Code 15840 involves the use of a graft to address facial nerve paralysis. Specifically, this code refers to the harvesting and transplantation of a free fascia graft, which is a type of connective tissue that provides structural support. The fascia is typically obtained from the fascia lata, a layer of tissue located in the thigh region. This harvested graft is then carefully transplanted to the facial area where paralysis has occurred. The surgical process includes suturing the graft beneath the skin to facilitate partial reanimation of the facial muscles that have been affected by paralysis. This procedure aims to restore some degree of movement and function to the face, improving the patient's appearance and quality of life. It is important to note that alternative codes exist for different types of grafts and techniques, such as a free muscle graft (CPT® Code 15841), a free muscle flap with microsurgical technique (CPT® Code 15842), and a regional muscle transfer (CPT® Code 15845), each indicating specific methods and materials used in the surgical intervention.
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The procedure associated with CPT® Code 15840 is indicated for patients experiencing facial nerve paralysis. This condition may arise from various causes, including trauma, surgical complications, or neurological disorders. The primary goal of the grafting procedure is to restore facial movement and improve aesthetic appearance in areas of the face that have been affected by paralysis.
The procedure for CPT® Code 15840 involves several critical steps to ensure successful grafting and restoration of facial function. First, the surgeon identifies the donor site, typically the fascia lata in the thigh, where the fascia will be harvested. This step requires careful dissection to obtain a sufficient amount of fascia while minimizing damage to surrounding tissues. Once the fascia is harvested, it is prepared for transplantation. The surgeon then makes an incision in the facial area where the paralysis is present. The harvested fascia graft is meticulously placed beneath the skin in the targeted area. The graft is then sutured into position to ensure stability and proper integration with the surrounding tissues. Throughout the procedure, the surgeon must maintain a focus on preserving the integrity of the facial structures and ensuring that the graft is positioned correctly to facilitate reanimation of the paralyzed muscles.
After the completion of the grafting procedure, patients typically require careful monitoring and follow-up care to assess the success of the graft and the recovery of facial function. Post-procedure care may include pain management, wound care to prevent infection, and physical therapy to encourage movement and rehabilitation of the facial muscles. Patients are often advised to avoid strenuous activities and to follow specific instructions regarding facial exercises to promote healing and optimize the results of the graft. The expected recovery period can vary depending on individual circumstances, but ongoing evaluation by the healthcare team is essential to ensure proper healing and to address any complications that may arise.
| Short Descr | NERVE PALSY FASCIAL GRAFT | Medium Descr | GRAFT FACIAL NERVE PARALYSIS FREE FASCIAL GRAFT | Long Descr | Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) | 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) | 0 - Co-surgeons not permitted for this procedure. | 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) | P5A - Ambulatory procedures - skin | MUE | 1 | CCS Clinical Classification | 172 - Skin graft |
| 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. | 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). | 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). | 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. | 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. | 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.) | 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.) | 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). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | 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 |
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| 2013-01-01 | Changed | Short Descriptor changed. |
| Pre-1990 | Added | Code added. |
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