2025 CPT code 11971
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Integumentary System Surgery Feed
Removal of tissue expander(s) without insertion of prosthesis/implant.
Modifiers may be applicable.For example, Modifier 22 (Increased Procedural Services) might be used if significant scar tissue or complications made the removal unusually difficult. Modifier 50 (Bilateral Procedure) would be used if tissue expanders were removed from both sides of the body, such as in bilateral breast reconstruction.
Medical necessity must be clearly documented and should explain why the expander is being removed without a replacement implant. This may include situations where sufficient tissue expansion has been achieved, patient choice to delay or decline further reconstruction, or complications related to the expander.
The physician is responsible for the entire surgical procedure including incision, expander removal, wound closure, and post-operative care. They must also document the medical necessity of the procedure.
In simple words: The doctor removes a balloon-like device called a tissue expander from under the skin.This device is sometimes used to stretch the skin before a permanent implant is put in. This procedure only involves taking out the expander, not putting in a new implant.
This code describes the surgical removal of a tissue expander without the placement of a subsequent implant or prosthesis.It involves an incision over the tissue expander site, careful extraction of the expander, and closure of the surgical wound.
Example 1: A patient had a tissue expander placed after a burn injury to prepare the skin for a graft. The skin has now stretched sufficiently, the expander is removed, and the grafting procedure is performed at a later date., A patient undergoing breast reconstruction had a tissue expander placed. After achieving the desired tissue expansion, the expander is removed, but the patient opts to delay placement of the permanent breast implant., A tissue expander was used in a patient following skin cancer removal on the scalp. After adequate tissue expansion, it is removed without a subsequent implant being placed as the expanded skin is sufficient for closure of the wound.
Documentation should include the location of the tissue expander, the reason for its initial placement, the size and type of expander removed, operative details, and any complications encountered. Medical necessity for removal without replacement should be clearly justified.Pre- and post-operative photographs are recommended.
- Specialties:Plastic Surgery, Reconstructive Surgery, General Surgery, Burn Surgery
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient, Physician's Office