2025 CPT code 15630
Effective Date: N/A Surgery - Surgical Procedures on the Integumentary System Feed
Delay of flap or sectioning of flap (division and inset) at eyelids, nose, ears, or lips.
Modifier 58 may be appended to this code if the division and inset is performed as a staged or related procedure during the postoperative period of the initial flap creation. Modifier 59 may be appended when a distinct procedural service is performed in addition to 15630, such as a skin graft or local flap repair at the donor site.
Medical necessity for this procedure should be justified by the presence of a defect or wound requiring reconstruction in the specified locations (eyelids, nose, ears, or lips). The documentation must support the need for a delayed flap procedure to optimize the blood supply and ensure successful reconstruction.
The surgeon performs the procedure under appropriate anesthesia. They divide the pedicle flap, suture the donor site, and inset the graft at the recipient site, closing both sites in layers. This often involves careful handling of delicate tissues and meticulous suturing techniques to ensure proper healing and cosmetic outcomes in these visible areas.
In simple words: The surgeon moves a piece of skin and tissue (a flap) that was partially attached to its original location to its final position on the eyelids, nose, ears, or lips. The area where the flap was originally taken from is then closed.
This procedure involves dividing a previously created pedicled flap from its base and completing the inset of the graft at the eyelids, nose, ears, or lips. It also includes the repair of the remaining wound at the donor site where the flap was pedicled.
Example 1: A patient with a defect on their eyelid following skin cancer removal undergoes a pedicle flap delay procedure. After sufficient time for the flap to establish blood supply, the surgeon performs code 15630 to complete the transfer and inset of the flap onto the eyelid, reconstructing the defect., Following trauma, a patient has a nasal defect. A pedicle flap is created, and after a period, the surgeon performs 15630 to detach and inset the flap onto the nose, restoring the nasal structure., A patient requires lip reconstruction after a burn injury. A pedicle flap is prepared, and once ready, 15630 describes the surgical detachment and placement of the flap onto the lip, restoring its function and appearance.
Documentation should include details about the size and location of the defect, the type of flap used, the method of flap creation, the date of the initial flap creation, the recipient site location (eyelid, nose, ear, or lip), and the complexity of the repair.
- Global Days: This procedure typically has a global period of 90 days.
- Specialties:Plastic Surgery, Reconstructive Surgery, Oculoplastic Surgery, Facial Plastic Surgery, Otolaryngology, and potentially Dermatology or Oral and Maxillofacial Surgery, depending on the location of the defect.
- Place of Service: Ambulatory Surgical Center, Hospital Outpatient Department, Physician's Office