2025 CPT code 15769
(Active) Effective Date: N/A Revision Date: N/A Surgery - Other Flaps and Grafts Procedures Integumentary System Feed
Grafting of autologous soft tissue (e.g., fat, dermis, fascia) harvested by direct excision.
Modifiers may be used with CPT code 15769 as clinically indicated. For example, modifier 51 (Multiple Procedures) may be applied if multiple grafts are harvested and placed.Modifier 59 (Distinct Procedural Service) may be necessary if the procedure is distinct from other procedures performed on the same day.Always refer to the official CPT guidelines and the payer's instructions for appropriate modifier use.
The medical necessity for CPT 15769 will be supported by the presence of a significant soft tissue defect that requires repair or reconstruction. The documentation should describe the nature, size, and location of the defect, and clearly demonstrate that the chosen surgical method is appropriate and medically necessary to restore normal tissue function and aesthetics.
The surgeon's responsibilities include: pre-operative assessment, marking the donor and recipient sites, surgical excision of the autologous soft tissue graft from the donor site, preparation of the recipient site, placement of the graft into the defect, closure of both donor and recipient sites, and appropriate postoperative care.
In simple words: The doctor removes a piece of your own tissue (like fat or skin) from one area of your body and uses it to fill a hole or repair damage in another area during the same surgery.The tissue is cut out directly, not using a suction method.
This CPT code describes the surgical procedure involving the harvesting of autologous soft tissue, such as fat, dermis, or fascia, through direct excision from a donor site.The harvested tissue is then grafted en bloc to a recipient site to repair a defect during the same operative session.This procedure excludes the use of liposuction for harvesting the soft tissue.For liposuction-harvested fat grafting, refer to CPT codes 15771-15774.
Example 1: A patient presents with a traumatic facial laceration resulting in a significant soft tissue defect. The surgeon uses CPT code 15769 to excise an autologous dermis graft from the patient's thigh to fill the defect., A patient requires breast reconstruction after a mastectomy. The surgeon uses CPT code 15769 to harvest a free autologous fat graft from the abdomen for transplantation into the breast region., A patient has a large wound on their leg due to a burn injury. The surgeon uses CPT code 15769 to remove a section of fascia from the patient's back and use it as an autologous graft to cover the burn wound.
Complete operative report detailing the surgical technique, including identification of the donor and recipient sites, type and amount of tissue harvested and grafted, and closure method used.Preoperative and postoperative photographs are also beneficial.Medical necessity documentation should justify the need for the grafting procedure.
** Careful consideration of the size and location of both the donor and recipient sites is crucial for appropriate code selection and reimbursement.Accurate documentation is paramount to ensure proper payment.Always consult the most up-to-date CPT and payer guidelines.
- RVU: Refer to the Medicare Physician Fee Schedule (MPFS) and your local Medicare Administrative Contractor (MAC) for current Relative Value Units (RVUs) and reimbursement rates.The relative value units will vary based on geographic location and other factors.
- Global Days: The global period for this procedure is not explicitly defined in the CPT guidelines but is likely to encompass the immediate postoperative period. More precise details are dependent on the payer's specific guidelines and may vary significantly.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier is not typically applicable to CPT code 15769.
- Fee Schedule: Historical fee schedules are not included in this response and would be dependent on time period and location.Contact your local Medicare Administrative Contractor (MAC) for historical fee information.
- Specialties:Plastic Surgery, Reconstructive Surgery, General Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center