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The procedure described by CPT® Code 15842 involves the use of a graft to address facial nerve paralysis through a specialized technique known as a free muscle flap by microsurgical means. In this context, a graft refers to a piece of tissue that is transplanted from one part of the body to another to restore function or appearance. Specifically, the fascia, which is a connective tissue that surrounds muscles, is typically harvested from the fascia lata, located in the leg. This harvested graft is then meticulously transplanted to the facial area where paralysis has occurred. The microsurgical technique employed allows for precise suturing of the graft beneath the skin, aiming to partially reanimate the facial muscles that have been affected by paralysis. This procedure is distinct from other related codes, such as CPT® Code 15841, which pertains to the use of a free muscle graft, and CPT® Code 15845, which involves a regional muscle transfer. The choice of code depends on the specific surgical technique and type of graft utilized during the procedure.
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The procedure associated with CPT® Code 15842 is indicated for patients suffering from facial nerve paralysis. This condition may arise from various causes, including traumatic injury, 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 careful selection of a donor site, typically the fascia lata from the leg, which is chosen for its suitable properties for grafting. The surgeon makes an incision at the donor site to access the fascia, which is then meticulously harvested. This step requires precision to ensure that the fascia is obtained without damaging surrounding tissues. Once the fascia is harvested, the surgeon prepares the facial area where the paralysis is present. This involves making an incision in the facial skin to create a pocket where the graft will be placed. The harvested fascia is then transplanted into this pocket and sutured beneath the skin. The microsurgical technique employed is critical, as it allows for the delicate manipulation of the graft and the surrounding tissues, ensuring proper alignment and integration. The suturing process is performed with great care to minimize scarring and optimize the aesthetic outcome. After the graft is securely in place, the incisions are closed, and the area is dressed appropriately to promote healing.
Post-procedure care is essential for optimal recovery following the grafting of facial nerve paralysis. Patients are typically monitored for any signs of complications, such as infection or graft failure. Pain management is provided as needed, and patients may be advised to avoid strenuous activities that could strain the surgical site. Follow-up appointments are crucial to assess the healing process and the effectiveness of the graft in restoring facial function. Rehabilitation may also be recommended, including physical therapy to help improve muscle movement and coordination in the affected areas. Patients should be informed about the expected recovery timeline and any signs that would necessitate immediate medical attention.
| Short Descr | NERVE PALSY MICROSURG GRAFT | Medium Descr | GRF FACIAL NRV PALYSS FR MUSCLE FLAP MICROSURG | Long Descr | Graft for facial nerve paralysis; free muscle flap by microsurgical technique | 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 | Non office-based surgical procedure added in CY 2008 or later; 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). | 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. | 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). | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2013-01-01 | Changed | Short Descriptor changed. |
| 2001-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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