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The procedure described by CPT® Code 15841 involves the use of a free muscle graft to address facial nerve paralysis. This condition can result in significant functional and aesthetic challenges for patients, as it affects the ability to control facial expressions. In this surgical intervention, the physician first obtains a graft, which is typically harvested from the fascia lata, a layer of connective tissue found in the leg. The harvested graft is then carefully transplanted to the facial area, where it is sutured beneath the skin. This technique aims to partially restore movement in the areas of the face that have been affected by paralysis. The use of a free muscle graft is specifically indicated in cases where traditional methods may not suffice, providing a more effective means of reanimating the facial muscles. It is important to note that this code is distinct from others in the same category, such as CPT® Code 15842, which pertains to free muscle flaps utilizing microsurgical techniques, and CPT® Code 15845, which refers to regional muscle transfers.
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The procedure associated with CPT® Code 15841 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 procedure is to restore facial function and improve aesthetic appearance by reanimating the paralyzed areas of the face.
The procedure begins with the physician identifying an appropriate donor site for the graft, which is commonly the fascia lata from the leg. The surgeon carefully dissects and harvests the fascia, ensuring that the graft is of sufficient size and quality for transplantation. Once the graft is obtained, the next step involves preparing the facial area for the graft placement. This includes making incisions in the skin to access the underlying tissues where the graft will be sutured. The physician then meticulously positions the free muscle graft beneath the skin of the face, aligning it with the areas affected by paralysis. The graft is secured in place using sutures, ensuring that it is properly anchored to facilitate integration with the surrounding tissues. Throughout the procedure, the surgeon monitors for any potential complications and ensures that the graft is adequately perfused to promote healing and functionality.
After the procedure, patients typically require monitoring for any signs of complications, such as infection or graft failure. Post-operative care may include pain management, wound care, and instructions for activity restrictions to promote healing. Patients are often advised to follow up with their healthcare provider to assess the integration of the graft and the restoration of facial function. The recovery process may vary depending on individual circumstances, but rehabilitation may be necessary to optimize outcomes and improve facial movement over time.
| Short Descr | NERVE PALSY MUSCLE GRAFT | Medium Descr | GRAFT FACIAL NERVE PARALYSIS FREE MUSCLE GRAFT | Long Descr | Graft for facial nerve paralysis; free muscle graft (including obtaining graft) | 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) | 2 - Payment restriction for assistants at surgery does not apply 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) | P5A - Ambulatory procedures - skin | MUE | 2 | CCS Clinical Classification | 172 - Skin graft |
| 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). | 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) |
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| 2013-01-01 | Changed | Short Descriptor changed. |
| Pre-1990 | Added | Code added. |
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