2025 CPT code 15736

Creation of a muscle, myocutaneous, or fasciocutaneous flap from the upper extremity.

Adhere to all CPT coding guidelines regarding wound repair and flap creation. Accurate measurement of wound dimensions is crucial for proper code selection. If multiple wounds require repair, follow CPT guidelines for adding together lengths of wounds within the same classification from the same anatomical group.

Modifiers may be applied depending on circumstances (e.g., 59 for a distinct procedural service, 22 for increased procedural service, etc.).Always refer to the most recent CPT guidelines and payer policies.

Medical necessity for a muscle, myocutaneous, or fasciocutaneous flap is established when other less invasive methods of wound closure are not feasible or appropriate.Factors considered include wound size, depth, location, presence of infection, and the patient's overall health.

The surgeon is responsible for all aspects of the procedure, including patient assessment, surgical planning and execution, flap creation, and closure of both donor and recipient sites.

IMPORTANT 15738 (lower extremity flap), 15756-15758 (microvascular flaps), 15570-15576 (flaps without vascular pedicle), 14000-14302 (adjacent tissue transfer flaps)

In simple words: The doctor takes a piece of skin, muscle, and/or fat tissue from the patient's arm (donor site) to repair a wound or injury elsewhere on the body (recipient site).The tissue is carefully moved and stitched into place, and both the donor and recipient sites are closed and dressed.

This CPT code encompasses the surgical creation of a muscle, myocutaneous, or fasciocutaneous flap harvested from the upper extremity of the patient.The procedure involves preparing both the donor site (upper extremity) and the recipient site (area requiring repair), meticulously creating the flap, ensuring vascular integrity, potentially tunneling the flap to the recipient site, securing it with sutures, and closing both donor and recipient sites with sutures.Appropriate dressings are applied post-procedure.

Example 1: A patient presents with a large traumatic wound on their lower leg due to a motor vehicle accident.A myocutaneous flap is harvested from the patient's forearm to cover the wound defect and promote healing., A patient requires breast reconstruction following a mastectomy. A myocutaneous flap is harvested from the patient's abdomen and transposed to the breast area., A patient experiences a significant soft tissue defect after a burn injury to their hand.A fasciocutaneous flap is created from the patient's thigh to cover the burn area and provide skin coverage.

Detailed operative report including:* Preoperative assessment and plan.* Description of the flap (type, location, size).* Details on the harvesting technique and vessel anastomosis if performed.* Description of recipient site preparation and flap placement.* Closure techniques and materials used.* Postoperative course and complications.* Photographs of the defect and repair.

** The complexity of the flap creation will influence the overall time and resources needed for the procedure. Accurate documentation is essential for appropriate reimbursement.Consult with coding specialists for complex cases.

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