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The procedure described by CPT® Code 15845 involves the use of a graft to address facial nerve paralysis through a technique known as regional muscle transfer. In this context, a graft refers to a piece of tissue that is surgically removed from one part of the body and transplanted to another area 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 carefully transplanted to the facial region, where it is sutured beneath the skin. The primary goal of this procedure is to partially reanimate areas of the face that have been affected by paralysis, thereby improving facial movement and aesthetics. It is important to note that this code is specifically designated for cases where a regional muscle transfer is performed, distinguishing it from other related procedures that may involve free muscle grafts or free muscle flaps utilizing microsurgical techniques, which are coded differently (CPT® Codes 15841 and 15842, respectively).
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The procedure associated with CPT® Code 15845 is indicated for patients experiencing facial nerve paralysis. This condition may arise from various causes, including trauma, surgical complications, or neurological disorders. The primary symptoms that may lead to the consideration of this procedure include:
The procedure for CPT® Code 15845 involves several critical steps to ensure the successful transfer of the graft for facial reanimation. The steps are as follows:
Following the procedure coded under CPT® Code 15845, patients can expect a recovery period that may involve specific post-operative care. This includes monitoring for any signs of infection at the donor and facial sites, managing pain with prescribed medications, and following up with the healthcare provider for suture removal and assessment of healing. Patients may also be advised to engage in physical therapy or facial exercises to enhance the effectiveness of the graft and improve facial movement over time. The overall recovery process can vary based on individual circumstances, but the goal is to achieve improved facial function and aesthetics.
| Short Descr | SKIN AND MUSCLE REPAIR FACE | Medium Descr | GRF FACIAL NERVE PARALYSIS REGIONAL MUSCLE TR | Long Descr | Graft for facial nerve paralysis; regional muscle transfer | 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) | 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 | 2 | CCS Clinical Classification | 172 - Skin graft |
| RT | Right side (used to identify procedures performed on the right side of the body) | 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. | 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 | E2 | Lower left, eyelid | E4 | Lower right, eyelid | 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) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2011-01-01 | Changed | Short description changed. |
| Pre-1990 | Added | Code added. |
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