2025 CPT code 15758
(Active) Effective Date: N/A Revision Date: N/A Surgical Procedures on the Integumentary System - Flaps and Grafts Surgery Feed
Free fascial flap with microvascular anastomosis involves transplanting a fascia piece from one body part to another, reconnecting it to blood vessels microsurgically.
Modifiers such as 22 (increased procedural services), 50 (bilateral procedure), 51 (multiple procedures), 52 (reduced services), 59 (distinct procedural service), and 62 (two surgeons) may be applicable depending on the circumstances of the procedure.
Medical necessity is established when the procedure is necessary to reconstruct significant tissue defects that cannot be adequately addressed with other less invasive techniques.The documentation should support the need for the free fascial flap based on the extent and complexity of the defect.
The surgeon performs the procedure, including harvesting the flap, preparing the recipient site, performing the microvascular anastomosis, and closing the donor and recipient sites.Anesthesiologist may be involved for general anesthesia.
In simple words: This surgery moves a piece of tissue with its own blood supply from one part of the body to another, carefully connecting the blood vessels to ensure the transplanted tissue heals and works correctly.
A free fascial flap with microvascular anastomosis is a surgical procedure where a fascial flap (a piece of fascia and its associated blood supply) is completely detached from its original location and transferred to a recipient site. Microsurgical techniques are used to connect the flap's blood vessels to vessels at the recipient site, ensuring adequate blood supply for the transplanted tissue to survive and function properly.This complex procedure often requires significant surgical expertise and advanced microsurgical skills.
Example 1: Reconstruction of a facial defect following trauma: A patient sustains a severe facial laceration resulting in significant tissue loss. A free fascial flap is harvested from the patient's thigh, microvascularly anastomosed, and used to reconstruct the damaged facial tissue., Breast reconstruction after mastectomy: Following a mastectomy, a free fascial flap is used to reconstruct the breast mound and restore the natural contour of the breast. This procedure may be combined with other reconstructive techniques., Repair of a complex wound following a burn: A patient with an extensive burn injury requires complex wound coverage. A free fascial flap is harvested and transferred to the burn site to provide durable coverage and facilitate healing.
Detailed operative notes, including description of the donor and recipient sites, size and type of flap, microvascular anastomosis technique, and assessment of flap viability.Preoperative and postoperative photographs, pathology reports (if applicable), and any complications encountered during or after the procedure should also be documented.
** The complexity of the procedure and the specific anatomical location of both donor and recipient sites can influence the time and resources required.Accurate reporting relies heavily on detailed and comprehensive documentation.
- Payment Status: Active
- Modifier TC rule: Not applicable to this code.
- Specialties:Plastic Surgery, Reconstructive Surgery, Microsurgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center