2025 CPT code 15842
(Active) Effective Date: N/A Revision Date: N/A Surgery - Other Repair (Closure) Procedures on the Integumentary System Surgery Feed
Microsurgical free muscle graft for facial nerve paralysis.
Modifiers may be applicable depending on the circumstances of the case (e.g., 51 for multiple procedures, 59 for unrelated procedures, 80 for assistant surgeon).
Medical necessity for 15842 is established by the presence of significant facial nerve paralysis impairing facial function and expression.The procedure is indicated when conservative management (e.g., physical therapy) has failed or is not expected to provide adequate improvement. The severity of facial paralysis should be clinically documented.
The clinical responsibility includes pre-operative planning, surgical procedure (including muscle harvesting, microsurgical vessel anastomosis, and muscle transplantation), and post-operative care. The surgeon must have expertise in microsurgery and reconstructive techniques.
In simple words: The doctor takes a piece of muscle from another part of the body (like the leg or back) and uses it to repair a paralyzed face. They use a special microscope and tiny tools to connect the blood vessels in the muscle to the face, restoring movement.
This CPT code 15842 represents the surgical procedure involving a microsurgical free muscle graft to repair facial nerve paralysis.The procedure includes harvesting a muscle graft (e.g., from the gracilis, pectoralis minor, latissimus dorsi, rectus abdominis, rectus femoris, or extensor digitorum brevis muscles), microsurgical anastomosis of the vessels within the graft to the recipient site in the face, and transplantation of the muscle to restore facial movement.The use of an operating microscope is inherent to the procedure and not separately reported.
Example 1: A patient presents with facial nerve paralysis following a stroke.A free gracilis muscle graft is harvested from the inner thigh and anastomosed to facial vessels using microsurgical techniques to restore facial symmetry and expression., A patient experiences facial nerve injury in a motor vehicle accident.The surgeon performs a microsurgical free muscle transfer of a portion of the latissimus dorsi muscle to reanimate the affected area., A patient has congenital facial paralysis. A combination of free muscle transfer and nerve grafting is undertaken. The surgeon uses a free rectus abdominis muscle transplant in combination with nerve grafting in a staged procedure to improve facial expression.
Detailed operative notes including the type of muscle used, the specific microsurgical technique, the location of the harvest site, the size of the graft, the number and caliber of vessels anastomosed, and intraoperative images of the procedure.Preoperative imaging (e.g., MRI or CT) to assess the extent of the nerve damage and plan the surgical approach.Postoperative photographs documenting the surgical outcome.
** This procedure requires specialized microsurgical skills and is typically performed in a dedicated operating room equipped with an operating microscope and appropriate microsurgical instruments.
- Payment Status: Active
- Modifier TC rule: Not applicable. This is a complete procedure.
- Specialties:Plastic Surgery, Neurosurgery, Oral and Maxillofacial Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center