Crystal's MCW Coder Hub🧬 CPT Code 15731 - Muscle, Myocutaneous, or Fasciocutaneous Flap; Head and Neck
Code Description
15731 - Muscle, myocutaneous, or fasciocutaneous flap; head and neck
This code represents a complex reconstructive surgical procedure involving the transfer of muscle, myocutaneous (muscle and skin), or fasciocutaneous (fascia and skin) tissue from one area to the head and neck region. The flap remains attached to its original blood supply (pedicled flap) or may be completely detached and reconnected microsurgically (free flap). This procedure is commonly used for reconstruction following tumor resection, trauma, or congenital defects in the head and neck area.
Key Components:
- Muscle Flap - Transfer of muscle tissue only
- Myocutaneous Flap - Transfer of muscle and overlying skin
- Fasciocutaneous Flap - Transfer of fascia and overlying skin
- Head and Neck Region - Includes scalp, face, oral cavity, pharynx, larynx, and neck
Critical Distinction:
- 15731 - Head and neck flaps
- 15732 - Trunk flaps
- 15733 - Upper extremity flaps
- 15734 - Lower extremity flaps
- 15750 - Free muscle, myocutaneous, or fasciocutaneous flap (microvascular)
Code Tree/Hierarchy
CPT Code Structure
└── Surgery (10000-69999)
└── Integumentary System (10000-19999)
└── Flaps (Skin and/or Deep Tissue) (15731-15758)
└── Muscle, Myocutaneous, or Fasciocutaneous Flap (15731-15734)
├── 15731 - Muscle, myocutaneous, or fasciocutaneous flap; head and neck
├── 15732 - Muscle, myocutaneous, or fasciocutaneous flap; trunk
├── 15733 - Muscle, myocutaneous, or fasciocutaneous flap; upper extremity
├── 15734 - Muscle, myocutaneous, or fasciocutaneous flap; lower extremity
└── 15750 - Free muscle, myocutaneous, or fasciocutaneous flap (microvascular)
└── Other Flap Procedures (15740-15758)
├── 15740 - Axial pattern flap
├── 15741 - Axial pattern flap; scalp, forehead, cheek, chin, mouth, neck
├── 15742 - Axial pattern flap; arm or leg
├── 15744 - Axial pattern flap; groin
├── 15745 - Axial pattern flap; foot
├── 15747 - Cross finger subcutaneous pedicle flap
├── 15748 - Cross finger pedicle flap
├── 15751 - Neurovascular pedicle flap
└── 15756-15758 - Free skin flap with microvascular anastomosis
Related ICD-10-CM Diagnosis Codes
Common Primary Diagnoses
Some of these codes are root codes and not the complete 7 character code
| ICD-10-CM Code | Description | HCC Status |
|---|---|---|
| C00.0 | Malignant neoplasm of external upper lip | HCC Category: Head/Neck Cancer (High Risk) |
| C00.1 | Malignant neoplasm of external lower lip | HCC Category: Head/Neck Cancer (High Risk) |
| C01 | Malignant neoplasm of base of tongue | HCC Category: Head/Neck Cancer (High Risk) |
| C02.0 | Malignant neoplasm of dorsal surface of tongue | HCC Category: Head/Neck Cancer (High Risk) |
| C02.1 | Malignant neoplasm of border of tongue | HCC Category: Head/Neck Cancer (High Risk) |
| C02.2 | Malignant neoplasm of ventral surface of tongue | HCC Category: Head/Neck Cancer (High Risk) |
| C02.3 | Malignant neoplasm of anterior two-thirds of tongue | HCC Category: Head/Neck Cancer (High Risk) |
| C02.4 | Malignant neoplasm of lingual tonsil | HCC Category: Head/Neck Cancer (High Risk) |
| C02.8 | Malignant neoplasm of overlapping sites of tongue | HCC Category: Head/Neck Cancer (High Risk) |
| C02.9 | Malignant neoplasm of tongue, unspecified | HCC Category: Head/Neck Cancer (High Risk) |
| C03.0 | Malignant neoplasm of upper gum | HCC Category: Head/Neck Cancer (High Risk) |
| C03.1 | Malignant neoplasm of lower gum | HCC Category: Head/Neck Cancer (High Risk) |
| C04.0 | Malignant neoplasm of anterior floor of mouth | HCC Category: Head/Neck Cancer (High Risk) |
| C04.1 | Malignant neoplasm of posterior floor of mouth | HCC Category: Head/Neck Cancer (High Risk) |
| C05.0 | Malignant neoplasm of hard palate | HCC Category: Head/Neck Cancer (High Risk) |
| C05.1 | Malignant neoplasm of soft palate | HCC Category: Head/Neck Cancer (High Risk) |
| C05.2 | Malignant neoplasm of uvula | HCC Category: Head/Neck Cancer (High Risk) |
| C06.0 | Malignant neoplasm of cheek mucosa | HCC Category: Head/Neck Cancer (High Risk) |
| C06.1 | Malignant neoplasm of vestibule of mouth | HCC Category: Head/Neck Cancer (High Risk) |
| C06.2 | Malignant neoplasm of retromolar area | HCC Category: Head/Neck Cancer (High Risk) |
| C07 | Malignant neoplasm of parotid gland | HCC Category: Head/Neck Cancer (High Risk) |
| C08.0 | Malignant neoplasm of submandibular gland | HCC Category: Head/Neck Cancer (High Risk) |
| C08.1 | Malignant neoplasm of sublingual gland | HCC Category: Head/Neck Cancer (High Risk) |
| C08.9 | Malignant neoplasm of major salivary gland | HCC Category: Head/Neck Cancer (High Risk) |
| C09.0 | Malignant neoplasm of tonsillar fossa | HCC Category: Head/Neck Cancer (High Risk) |
| C09.1 | Malignant neoplasm of tonsillar pillar | HCC Category: Head/Neck Cancer (High Risk) |
| C09.8 | Malignant neoplasm of overlapping sites of tonsil | HCC Category: Head/Neck Cancer (High Risk) |
| C09.9 | Malignant neoplasm of tonsil, unspecified | HCC Category: Head/Neck Cancer (High Risk) |
| C10.0 | Malignant neoplasm of vallecula | HCC Category: Head/Neck Cancer (High Risk) |
| C10.1 | Malignant neoplasm of anterior surface of epiglottis | HCC Category: Head/Neck Cancer (High Risk) |
| C10.2 | Malignant neoplasm of lateral wall of oropharynx | HCC Category: Head/Neck Cancer (High Risk) |
| C10.3 | Malignant neoplasm of posterior wall of oropharynx | HCC Category: Head/Neck Cancer (High Risk) |
| C10.4 | Malignant neoplasm of branchial cleft | HCC Category: Head/Neck Cancer (High Risk) |
| C10.8 | Malignant neoplasm of overlapping sites of oropharynx | HCC Category: Head/Neck Cancer (High Risk) |
| C10.9 | Malignant neoplasm of oropharynx, unspecified | HCC Category: Head/Neck Cancer (High Risk) |
| C11.0 | Malignant neoplasm of superior wall of nasopharynx | HCC Category: Head/Neck Cancer (High Risk) |
| C11.1 | Malignant neoplasm of posterior wall of nasopharynx | HCC Category: Head/Neck Cancer (High Risk) |
| C11.2 | Malignant neoplasm of lateral wall of nasopharynx | HCC Category: Head/Neck Cancer (High Risk) |
| C11.3 | Malignant neoplasm of anterior wall of nasopharynx | HCC Category: Head/Neck Cancer (High Risk) |
| C11.8 | Malignant neoplasm of overlapping sites of nasopharynx | HCC Category: Head/Neck Cancer (High Risk) |
| C11.9 | Malignant neoplasm of nasopharynx, unspecified | HCC Category: Head/Neck Cancer (High Risk) |
| C12 | Malignant neoplasm of piriform sinus | HCC Category: Head/Neck Cancer (High Risk) |
| C13.0 | Malignant neoplasm of postcricoid region | HCC Category: Head/Neck Cancer (High Risk) |
| C13.1 | Malignant neoplasm of aryepiglottic fold | HCC Category: Head/Neck Cancer (High Risk) |
| C13.2 | Malignant neoplasm of posterior wall of hypopharynx | HCC Category: Head/Neck Cancer (High Risk) |
| C13.8 | Malignant neoplasm of overlapping sites of hypopharynx | HCC Category: Head/Neck Cancer (High Risk) |
| C13.9 | Malignant neoplasm of hypopharynx, unspecified | HCC Category: Head/Neck Cancer (High Risk) |
| C32.0 | Malignant neoplasm of glottis | HCC Category: Head/Neck Cancer (High Risk) |
| C32.1 | Malignant neoplasm of supraglottis | HCC Category: Head/Neck Cancer (High Risk) |
| C32.2 | Malignant neoplasm of subglottis | HCC Category: Head/Neck Cancer (High Risk) |
| C32.3 | Malignant neoplasm of laryngeal cartilage | HCC Category: Head/Neck Cancer (High Risk) |
| C32.8 | Malignant neoplasm of overlapping sites of larynx | HCC Category: Head/Neck Cancer (High Risk) |
| C32.9 | Malignant neoplasm of larynx, unspecified | HCC Category: Head/Neck Cancer (High Risk) |
| C44.0 | Malignant neoplasm of skin of lip | HCC Category: Skin Cancer (Moderate Risk) |
| C44.3 | Malignant neoplasm of skin of face | HCC Category: Skin Cancer (Moderate Risk) |
| D00.00 | Carcinoma in situ of lip, oral cavity and pharynx, unspecified | HCC Category: Cancer (Moderate Risk) |
| D00.01 | Carcinoma in situ of lip | HCC Category: Cancer (Moderate Risk) |
| D00.02 | Carcinoma in situ of tongue | HCC Category: Cancer (Moderate Risk) |
| D10.0 | Benign neoplasm of lip | HCC: No |
| D10.1 | Benign neoplasm of tongue | HCC: No |
| D10.2 | Benign neoplasm of floor of mouth | HCC: No |
| D10.3 | Benign neoplasm of other and unspecified parts of mouth | HCC: No |
| D10.4 | Benign neoplasm of tonsil | HCC: No |
| D10.5 | Benign neoplasm of other parts of oropharynx | HCC: No |
| D10.6 | Benign neoplasm of nasopharynx | HCC: No |
| D10.7 | Benign neoplasm of hypopharynx | HCC: No |
| K08.0 | Exfoliation of teeth due to systemic causes | HCC: No |
| K08.1 | Complete loss of teeth | HCC: No |
| K08.2 | Atrophy of edentulous alveolar ridge | HCC: No |
| K08.3 | Retained dental root | HCC: No |
| K08.4 | Incomplete dental eruption | HCC: No |
| K08.5 | Acquired dentofacial anomalies | HCC: No |
| K08.8 | Other specified disorders of teeth and supporting structures | HCC: No |
| K08.9 | Disorder of teeth and supporting structures, unspecified | HCC: No |
| K11.0 | Atrophy of salivary gland | HCC: No |
| K11.1 | Hypertrophy of salivary gland | HCC: No |
| K11.2 | Sialadenitis | HCC: No |
| K11.3 | Abscess of salivary gland | HCC: No |
| K11.4 | Fistula of salivary gland | HCC: No |
| K11.5 | Sialolithiasis | HCC: No |
| K11.6 | Mucocele of salivary gland | HCC: No |
| K11.7 | Disturbances of salivary secretion | HCC: No |
| K11.8 | Other diseases of salivary glands | HCC: No |
| K11.9 | Disease of salivary gland, unspecified | HCC: No |
| K12.0 | Recurrent oral aphthae | HCC: No |
| K12.1 | Other forms of stomatitis | HCC: No |
| K12.2 | Cellulitis and abscess of mouth | HCC: No |
| K12.3 | Oral mucositis (ulcerative) | HCC: No |
| K13.0 | Diseases of lips | HCC: No |
| K13.1 | Cheek and lip biting | HCC: No |
| K13.2 | Leukoplakia and other disturbances of oral epithelium, including tongue | HCC: No |
| K13.3 | Hairy tongue | HCC: No |
| K13.4 | Granuloma and granuloma-like lesions of oral mucosa | HCC: No |
| K13.5 | Oral submucous fibrosis | HCC: No |
| K13.6 | Irritative hyperplasia of oral mucosa | HCC: No |
| K13.7 | Other and unspecified lesions of oral mucosa | HCC: No |
| L51.0 | Nonbullous erythema multiforme | HCC: No |
| L51.1 | Bullous erythema multiforme | HCC: No |
| L51.2 | Toxic epidermal necrolysis [Lyell] | HCC: No |
| L51.3 | Stevens-Johnson syndrome | HCC: No |
| L51.8 | Other erythema multiforme | HCC: No |
| L51.9 | Erythema multiforme, unspecified | HCC: No |
| M26.0 | Major anomalies of jaw size | HCC: No |
| M26.1 | Major anomalies of jaw-cranial base relationship | HCC: No |
| M26.2 | Dentofacial functional abnormalities | HCC: No |
| M26.3 | Dentofacial functional abnormalities | HCC: No |
| M26.4 | Malocclusion, unspecified | HCC: No |
| M26.5 | Temporomandibular joint disorders | HCC: No |
| M26.6 | Temporomandibular joint disorders | HCC: No |
| M26.7 | Acquired dentofacial anomalies | HCC: No |
| M26.8 | Other dentofacial anomalies | HCC: No |
| M26.9 | Dentofacial anomaly, unspecified | HCC: No |
| M27.0 | Developmental anomalies of jaws | HCC: No |
| M27.1 | Macrognathism | HCC: No |
| M27.2 | Micrognathism | HCC: No |
| M27.3 | Excessive tuberosity of jaw | HCC: No |
| M27.4 | Other developmental anomalies of jaws | HCC: No |
| M27.5 | Other developmental anomalies of jaws | HCC: No |
| M27.6 | Other developmental anomalies of jaws | HCC: No |
| M27.8 | Other specified diseases of jaws | HCC: No |
| M27.9 | Disease of jaws, unspecified | HCC: No |
| Q10.0 | Congenital ptosis of eyelid | HCC: No |
| Q10.1 | Congenital ectropion of eyelid | HCC: No |
| Q10.2 | Congenital entropion of eyelid | HCC: No |
| Q10.3 | Other congenital malformations of eyelid | HCC: No |
| Q10.4 | Congenital absence of eyelid | HCC: No |
| Q10.5 | Congenital stenosis and stricture of lacrimal duct | HCC: No |
| Q10.6 | Congenital absence of lacrimal apparatus | HCC: No |
| Q10.7 | Congenital malformation of lacrimal apparatus | HCC: No |
| Q11.0 | Cystic eyeball | HCC: No |
| Q11.1 | Other anophthalmos | HCC: No |
| Q11.2 | Microphthalmos | HCC: No |
| Q11.3 | Macrophthalmos | HCC: No |
| Q13.0 | Coloboma of iris | HCC: No |
| Q13.1 | Absence of iris | HCC: No |
| Q13.2 | Other congenital malformations of anterior segment of eye | HCC: No |
| Q13.3 | Congenital corneal opacity | HCC: No |
| Q13.4 | Other congenital corneal anomalies | HCC: No |
| Q13.5 | Blue sclera | HCC: No |
| Q13.6 | Other congenital anomalies of anterior chamber | HCC: No |
| Q13.7 | Other congenital anomalies of anterior chamber | HCC: No |
| Q13.8 | Other congenital malformations of anterior segment of eye | HCC: No |
| Q13.9 | Congenital malformation of anterior segment of eye, unspecified | HCC: No |
| Q16.0 | Congenital absence of (ear) auricle | HCC: No |
| Q16.1 | Congenital absence, atresia and stricture of auditory canal (external) | HCC: No |
| Q16.2 | Absence of eustachian tube | HCC: No |
| Q16.3 | Congenital malformation of ear ossicles | HCC: No |
| Q16.4 | Other congenital malformations of middle ear | HCC: No |
| Q16.5 | Congenital malformation of inner ear | HCC: No |
| Q16.9 | Congenital malformation of ear causing impairment of hearing, unspecified | HCC: No |
| Q17.0 | Accessory auricle | HCC: No |
| Q17.1 | Macrotia | HCC: No |
| Q17.2 | Microtia | HCC: No |
| Q17.3 | Other misformed ear | HCC: No |
| Q17.4 | Malposition of ear | HCC: No |
| Q17.5 | Prominent ear | HCC: No |
| Q17.8 | Other specified congenital malformations of ear | HCC: No |
| Q17.9 | Congenital malformation of ear, unspecified | HCC: No |
| Q18.0 | Branchial cleft sinus, fistula and cyst | HCC: No |
| Q18.1 | Preauricular sinus and cyst | HCC: No |
| Q18.2 | Other branchial cleft malformations | HCC: No |
| Q18.3 | Webbing of neck | HCC: No |
| Q18.4 | Macrostomia | HCC: No |
| Q18.5 | Microstomia | HCC: No |
| Q18.6 | Other specified congenital malformations of face and neck | HCC: No |
| Q18.7 | Other specified congenital malformations of face and neck | HCC: No |
| Q18.8 | Other specified congenital malformations of face and neck | HCC: No |
| Q18.9 | Congenital malformation of face and neck, unspecified | HCC: No |
| Q27.0 | Absence of hypoglossal nerve | HCC: No |
| Q27.1 | Congenital stenosis of pulmonary artery | HCC: No |
| Q27.2 | Other congenital malformations of renal artery | HCC: No |
| Q27.3 | Peripheral vascular malformations | HCC: No |
| Q27.4 | Other congenital malformations of peripheral vascular system | HCC: No |
| Q27.5 | Other congenital malformations of peripheral vascular system | HCC: No |
| Q27.8 | Other specified congenital malformations of peripheral vascular system | HCC: No |
| Q27.9 | Congenital malformation of peripheral vascular system, unspecified | HCC: No |
| Q38.0 | Congenital malformations of lips, not elsewhere classified | HCC: No |
| Q38.1 | Ankyloglossia | HCC: No |
| Q38.2 | Macroglossia | HCC: No |
| Q38.3 | Other congenital malformations of tongue | HCC: No |
| Q38.4 | Congenital malformations of salivary glands | HCC: No |
| Q38.5 | Congenital malformations of palate, not elsewhere classified | HCC: No |
| Q38.6 | Other congenital malformations of mouth | HCC: No |
| Q38.7 | Pharyngeal pouch | HCC: No |
| Q38.8 | Other congenital malformations of pharynx | HCC: No |
| Q39.0 | Atresia of esophagus without fistula | HCC: No |
| Q39.1 | Atresia of esophagus with tracheoesophageal fistula | HCC: No |
| Q39.2 | Congenital tracheoesophageal fistula without atresia | HCC: No |
| Q39.3 | Congenital stenosis and stricture of esophagus | HCC: No |
| Q39.4 | Esophageal web | HCC: No |
| Q39.5 | Congenital dilation of esophagus | HCC: No |
| Q39.6 | Diverticulum of esophagus | HCC: No |
| Q39.8 | Other congenital malformations of esophagus | HCC: No |
| Q39.9 | Congenital malformation of esophagus, unspecified | HCC: No |
| Q43.0 | Meckel’s diverticulum | HCC: No |
| Q43.1 | Hirschsprung’s disease | HCC: No |
| Q43.2 | Other congenital functional disorders of colon | HCC: No |
| Q43.3 | Congenital malformations of intestinal fixation | HCC: No |
| Q43.4 | Duplications of intestine | HCC: No |
| Q43.5 | Ectopic anus | HCC: No |
| Q43.6 | Congenital fistula of rectum and anus | HCC: No |
| Q43.7 | Persistent cloaca | HCC: No |
| Q43.8 | Other specified congenital malformations of intestine | HCC: No |
| Q43.9 | Congenital malformation of intestine, unspecified | HCC: No |
| S00.0 | Superficial injury of scalp | HCC: No |
| S00.1 | Contusion of eyelid and periocular area | HCC: No |
| S00.2 | Other superficial injuries of eyelid and periocular area | HCC: No |
| S00.3 | Superficial injury of nose | HCC: No |
| S00.4 | Superficial injury of ear | HCC: No |
| S00.5 | Superficial injury of lip and oral cavity | HCC: No |
| S00.7 | Multiple superficial injuries of head | HCC: No |
| S00.8 | Superficial injury of other parts of head | HCC: No |
| S00.9 | Superficial injury of head, part unspecified | HCC: No |
| S01.0 | Open wound of scalp | HCC: No |
| S01.1 | Open wound of eyelid and periocular area | HCC: No |
| S01.2 | Open wound of nose | HCC: No |
| S01.3 | Open wound of ear | HCC: No |
| S01.4 | Open wound of cheek and temporomandibular area | HCC: No |
| S01.5 | Open wound of lip and oral cavity | HCC: No |
| S01.7 | Multiple open wounds of head | HCC: No |
| S01.8 | Open wound of other parts of head | HCC: No |
| S01.9 | Open wound of head, part unspecified | HCC: No |
| S02.0 | Fracture of vault of skull | HCC: No |
| S02.1 | Fracture of base of skull | HCC: No |
| S02.2 | Fracture of nasal bones | HCC: No |
| S02.3 | Fracture of orbital floor | HCC: No |
| S02.4 | Fracture of malar and maxillary bones | HCC: No |
| S02.5 | Fracture of tooth | HCC: No |
| S02.6 | Fracture of mandible | HCC: No |
| S02.7 | Multiple fractures involving skull and facial bones | HCC: No |
| S02.8 | Fractures of other skull and facial bones | HCC: No |
| S02.9 | Fracture of skull and facial bones, part unspecified | HCC: No |
| S03.0 | Traumatic subluxation and dislocation of jaw | HCC: No |
| S03.1 | Traumatic subluxation and dislocation of septal cartilage of nose | HCC: No |
| S03.2 | Dislocation of tooth | HCC: No |
| S03.3 | Dislocation of other and unspecified parts of head | HCC: No |
| S03.4 | Sprain and strain of jaw | HCC: No |
| S03.5 | Sprain and strain of other and unspecified parts of head | HCC: No |
| S04.0 | Injury of optic nerve and pathways | HCC: No |
| S04.1 | Injury of oculomotor nerve | HCC: No |
| S04.2 | Injury of trochlear nerve | HCC: No |
| S04.3 | Injury of trigeminal nerve | HCC: No |
| S04.4 | Injury of abducent nerve | HCC: No |
| S04.5 | Injury of facial nerve | HCC: No |
| S04.6 | Injury of acoustic nerve | HCC: No |
| S04.7 | Injury of accessory nerve | HCC: No |
| S04.8 | Injury of other cranial nerves | HCC: No |
| S04.9 | Injury of unspecified cranial nerve | HCC: No |
| S05.0 | Injury of conjunctiva and corneal abrasion without foreign body | HCC: No |
| S05.1 | Contusion of eyeball and orbital tissues | HCC: No |
| S05.2 | Ocular laceration and rupture with prolapse or loss of intraocular tissue | HCC: No |
| S05.3 | Ocular laceration and rupture without prolapse or loss of intraocular tissue | HCC: No |
| S05.4 | Injury of conjunctiva and corneal abrasion without foreign body | HCC: No |
| S05.5 | Penetrating wound of orbit with or without foreign body | HCC: No |
| S05.6 | Penetrating wound of eyeball with foreign body | HCC: No |
| S05.7 | Avulsion of eye | HCC: No |
| S05.8 | Other injuries of eye and orbit | HCC: No |
| S05.9 | Unspecified injury of eye and orbit | HCC: No |
| S06.0 | Concussion | HCC: No |
| S06.1 | Traumatic cerebral edema | HCC: No |
| S06.2 | Diffuse traumatic brain injury | HCC: No |
| S06.3 | Focal traumatic brain injury | HCC: No |
| S06.4 | Epidural hemorrhage | HCC: No |
| S06.5 | Traumatic subdural hemorrhage | HCC: No |
| S06.6 | Traumatic subarachnoid hemorrhage | HCC: No |
| S06.7 | Intracranial injury with prolonged loss of consciousness | HCC: No |
| S06.8 | Other intracranial injuries | HCC: No |
| S06.9 | Intracranial injury, unspecified | HCC: No |
| S07.0 | Crushing injury of face | HCC: No |
| S07.1 | Crushing injury of skull | HCC: No |
| S07.8 | Crushing injury of other parts of head | HCC: No |
| S07.9 | Crushing injury of head, part unspecified | HCC: No |
| S08.0 | Avulsion of scalp | HCC: No |
| S08.1 | Traumatic amputation of ear | HCC: No |
| S08.2 | Avulsion of other parts of head | HCC: No |
| S08.3 | Traumatic amputation of other parts of head | HCC: No |
| S08.8 | Avulsion of unspecified part of head | HCC: No |
| S08.9 | Traumatic amputation of unspecified part of head | HCC: No |
| S09.0 | Injury of blood vessels of head, not elsewhere classified | HCC: No |
| S09.1 | Injury of muscle and tendon of head | HCC: No |
| S09.2 | Traumatic rupture of ear drum | HCC: No |
| S09.7 | Multiple injuries of head | HCC: No |
| S09.8 | Other specified injuries of head | HCC: No |
| S09.9 | Unspecified injury of head | HCC: No |
| T20.0 | Burn of unspecified degree of head, face and neck | HCC: No |
| T20.1 | Burn of first degree of head, face and neck | HCC: No |
| T20.2 | Burn of second degree of head, face and neck | HCC: No |
| T20.3 | Burn of third degree of head, face and neck | HCC: No |
| T20.4 | Corrosion of unspecified degree of head, face and neck | HCC: No |
| T20.5 | Corrosion of first degree of head, face and neck | HCC: No |
| T20.6 | Corrosion of second degree of head, face and neck | HCC: No |
| T20.7 | Corrosion of third degree of head, face and neck | HCC: No |
| T21.0 | Burn of unspecified degree of trunk | HCC: No |
| T21.1 | Burn of first degree of trunk | HCC: No |
| T21.2 | Burn of second degree of trunk | HCC: No |
| T21.3 | Burn of third degree of trunk | HCC: No |
| T21.4 | Corrosion of unspecified degree of trunk | HCC: No |
| T21.5 | Corrosion of first degree of trunk | HCC: No |
| T21.6 | Corrosion of second degree of trunk | HCC: No |
| T21.7 | Corrosion of third degree of trunk | HCC: No |
| T22.0 | Burn of unspecified degree of shoulder and upper limb, except wrist and hand | HCC: No |
| T22.1 | Burn of first degree of shoulder and upper limb, except wrist and hand | HCC: No |
| T22.2 | Burn of second degree of shoulder and upper limb, except wrist and hand | HCC: No |
| T22.3 | Burn of third degree of shoulder and upper limb, except wrist and hand | HCC: No |
| T22.4 | Corrosion of unspecified degree of shoulder and upper limb, except wrist and hand | HCC: No |
| T22.5 | Corrosion of first degree of shoulder and upper limb, except wrist and hand | HCC: No |
| T22.6 | Corrosion of second degree of shoulder and upper limb, except wrist and hand | HCC: No |
| T22.7 | Corrosion of third degree of shoulder and upper limb, except wrist and hand | HCC: No |
| T23.0 | Burn of unspecified degree of wrist and hand | HCC: No |
| T23.1 | Burn of first degree of wrist and hand | HCC: No |
| T23.2 | Burn of second degree of wrist and hand | HCC: No |
| T23.3 | Burn of third degree of wrist and hand | HCC: No |
| T23.4 | Corrosion of unspecified degree of wrist and hand | HCC: No |
| T23.5 | Corrosion of first degree of wrist and hand | HCC: No |
| T23.6 | Corrosion of second degree of wrist and hand | HCC: No |
| T23.7 | Corrosion of third degree of wrist and hand | HCC: No |
| T24.0 | Burn of unspecified degree of hip and lower limb, except ankle and foot | HCC: No |
| T24.1 | Burn of first degree of hip and lower limb, except ankle and foot | HCC: No |
| T24.2 | Burn of second degree of hip and lower limb, except ankle and foot | HCC: No |
| T24.3 | Burn of third degree of hip and lower limb, except ankle and foot | HCC: No |
| T24.4 | Corrosion of unspecified degree of hip and lower limb, except ankle and foot | HCC: No |
| T24.5 | Corrosion of first degree of hip and lower limb, except ankle and foot | HCC: No |
| T24.6 | Corrosion of second degree of hip and lower limb, except ankle and foot | HCC: No |
| T24.7 | Corrosion of third degree of hip and lower limb, except ankle and foot | HCC: No |
| T25.0 | Burn of unspecified degree of ankle and foot | HCC: No |
| T25.1 | Burn of first degree of ankle and foot | HCC: No |
| T25.2 | Burn of second degree of ankle and foot | HCC: No |
| T25.3 | Burn of third degree of ankle and foot | HCC: No |
| T25.4 | Corrosion of unspecified degree of ankle and foot | HCC: No |
| T25.5 | Corrosion of first degree of ankle and foot | HCC: No |
| T25.6 | Corrosion of second degree of ankle and foot | HCC: No |
| T25.7 | Corrosion of third degree of ankle and foot | HCC: No |
| T26.0 | Burn of cornea and conjunctival sac | HCC: No |
| T26.1 | Burn of eyelid and periocular area | HCC: No |
| T26.2 | Burn with resulting rupture and destruction of eyeball | HCC: No |
| T26.3 | Burn of other parts of eye and adnexa | HCC: No |
| T26.4 | Burn of eye and adnexa, part unspecified | HCC: No |
| T26.5 | Corrosion of cornea and conjunctival sac | HCC: No |
| T26.6 | Corrosion of eyelid and periocular area | HCC: No |
| T26.7 | Corrosion with resulting rupture and destruction of eyeball | HCC: No |
| T26.8 | Corrosion of other parts of eye and adnexa | HCC: No |
| T26.9 | Corrosion of eye and adnexa, part unspecified | HCC: No |
| T27.0 | Burn of larynx and trachea | HCC: No |
| T27.1 | Burn of larynx and trachea with lung | HCC: No |
| T27.2 | Burn of other parts of respiratory tract | HCC: No |
| T27.3 | Burn of respiratory tract, part unspecified | HCC: No |
| T27.4 | Corrosion of larynx and trachea | HCC: No |
| T27.5 | Corrosion of larynx and trachea with lung | HCC: No |
| T27.6 | Corrosion of other parts of respiratory tract | HCC: No |
| T27.7 | Corrosion of respiratory tract, part unspecified | HCC: No |
| T28.0 | Burn of mouth and pharynx | HCC: No |
| T28.1 | Burn of esophagus | HCC: No |
| T28.2 | Burn of other parts of alimentary tract | HCC: No |
| T28.3 | Burn of internal genitourinary organs | HCC: No |
| T28.4 | Burn of other and unspecified internal organs | HCC: No |
| T28.5 | Corrosion of mouth and pharynx | HCC: No |
| T28.6 | Corrosion of esophagus | HCC: No |
| T28.7 | Corrosion of other parts of alimentary tract | HCC: No |
| T28.8 | Corrosion of internal genitourinary organs | HCC: No |
| T28.9 | Corrosion of other and unspecified internal organs | HCC: No |
| T31.0 | Burn less than 10% of body surface | HCC: No |
| T31.10 | Burn 10-19% of body surface | HCC: No |
| T31.20 | Burn 20-29% of body surface | HCC: No |
| T31.30 | Burn 30-39% of body surface | HCC: No |
| T31.40 | Burn 40-49% of body surface | HCC: No |
| T31.50 | Burn 50-59% of body surface | HCC: No |
| T31.60 | Burn 60-69% of body surface | HCC: No |
| T31.70 | Burn 70-79% of body surface | HCC: No |
| T31.80 | Burn 80-89% of body surface | HCC: No |
| T31.90 | Burn 90% or more of body surface | HCC: No |
| T32.00 | Corrosion less than 10% of body surface | HCC: No |
| T32.10 | Corrosion 10-19% of body surface | HCC: No |
| T32.20 | Corrosion 20-29% of body surface | HCC: No |
| T32.30 | Corrosion 30-39% of body surface | HCC: No |
| T32.40 | Corrosion 40-49% of body surface | HCC: No |
| T32.50 | Corrosion 50-59% of body surface | HCC: No |
| T32.60 | Corrosion 60-69% of body surface | HCC: No |
| T32.70 | Corrosion 70-79% of body surface | HCC: No |
| T32.80 | Corrosion 80-89% of body surface | HCC: No |
| T32.90 | Corrosion 90% or more of body surface | HCC: No |
External Cause Codes (Reference: ICD-10-CM External Cause Index 2025)1
Note: External cause codes are required if the condition resulted from injury, trauma, or other external causes. Based on the ICD-10-CM External Cause Index 2025:
Some of these codes are root codes and not the complete 7 character code
| Category | Code Example | Description from Index |
|---|---|---|
| Place of Occurrence (Y92) | Y92.009 | Private residence (unspecified) |
| Y92.239 | Hospital (unspecified) | |
| Y92.531 | Dentist office | |
| Y92.63 | Factory (building)(premises) | |
| Y92.293 | Restaurant | |
| Y92.832 | Beach | |
| Y92.813 | Airplane | |
| Activity (Y93) | Y93.83 | Food preparation |
| Y93.89 | Activity specified NEC | |
| Y93.61 | Football (American) NOS | |
| Y93.15 | SCUBA diving | |
| Y93.01 | Walking (on level or elevated terrain) | |
| Y93.71 | Boxing | |
| Y93.75 | Martial arts | |
| Status (Y99) | Y99.0 | Civilian activity done for income or pay |
| Y99.8 | Leisure activity | |
| Y99.1 | Military activity | |
| Y99.2 | Volunteer activity | |
| Specific Injury | W26.9 | Contact with sharp object, unspecified |
| W25.0 | Contact with broken glass | |
| W51.0 | Collision with another person | |
| W50.0 | Struck by other person | |
| X92-Y08 | Assault codes | |
| X71-X83 | Self-harm codes |
Usage Note: Assign external cause codes per ICD-10-CM External Cause Index 2025 guidelines if the medical record documents an external cause (e.g., trauma, assault, accident) leading to the head and neck defect requiring flap reconstruction. For routine cancer resection reconstruction, external cause codes are not applicable.1
Includes
- Muscle Flap Transfer - Movement of muscle tissue to head and neck region
- Myocutaneous Flap - Combined muscle and skin transfer
- Fasciocutaneous Flap - Combined fascia and skin transfer
- Pedicled Flap - Flap remains attached to original blood supply
- Head and Neck Region - Scalp, face, oral cavity, pharynx, larynx, neck
- Flap Elevation - dissection and mobilization of flap tissue
- Flap Inset - Suturing and securing flap to recipient site
- Donor Site Closure - Repair of area where flap was harvested
- Microvascular Anastomosis - If free flap technique used (may require 15750)
- Nerve Coaptation - If sensory or motor nerve repair performed
- Immediate Post-op Care - Recovery room monitoring
Excludes
| Code | Description | Reason |
|---|---|---|
| 15732 | Muscle, myocutaneous, or fasciocutaneous flap; trunk | Different anatomical region |
| 15733 | Muscle, myocutaneous, or fasciocutaneous flap; upper extremity | Different anatomical region |
| 15734 | Muscle, myocutaneous, or fasciocutaneous flap; lower extremity | Different anatomical region |
| 15750 | Free muscle, myocutaneous, or fasciocutaneous flap (microvascular) | Free flap with microvascular anastomosis |
| 15740 | Axial pattern flap | Different flap type |
| 15741 | Axial pattern flap; scalp, forehead, cheek, chin, mouth, neck | Different flap type |
| 15756 | Free skin flap with microvascular anastomosis | Skin only, not muscle/fascia |
| 15757 | Free skin flap with microvascular anastomosis; with vascular pedicle | Different flap type |
| 15758 | Free skin flap with microvascular anastomosis; without vascular pedicle | Different flap type |
| 15570 | Pedicle flap; division and inset | Staged procedure |
| 15610 | Delay of flap or sectioning of flap (division and inset) | Staged procedure |
| 15620 | Delay of flap; trunk | Different region |
| 15630 | Delay of flap; arm or leg | Different region |
| 11042 | Debridement; subcutaneous tissue | Separate procedure |
| 11043 | Debridement; muscle and/or fascia | May be bundled |
| 11044 | Debridement; bone | Separate procedure |
| 13131 | Repair complex; scalp, arms, and/or legs | Different repair type |
| 13132 | Repair complex; cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet | May be bundled |
| 13133 | Repair complex; forehead, cheeks, chin, mouth, neck, ears, orbits, scalp, fingers, and/or toes | May be bundled |
| 14000 | Adjacent tissue transfer or rearrangement; defect 10 sq cm or less | Different reconstruction type |
| 14001 | Adjacent tissue transfer or rearrangement; defect 10.1-30.0 sq cm | Different reconstruction type |
| 14020 | Adjacent tissue transfer or rearrangement; defect 30.1-60.0 sq cm | Different reconstruction type |
Assistant Surgeon Information
| Payer Type | Assistant Payable | Typical Reimbursement |
|---|---|---|
| Medicare | Yes (Status Indicator 1) | 16% of surgeon fee |
| Commercial | Varies by contract | 10-20% of surgeon fee |
| Medicaid | Varies by state | 10-16% of surgeon fee |
Modifiers for Assistant Surgeon:
- -80 - Assistant surgeon
- -81 - Minimum assistant surgeon
- -82 - Assistant surgeon (when qualified resident not available)
- -AS - Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
Note: Due to the complexity and depth of head and neck flap reconstruction, assistant surgeons are commonly utilized and reimbursed. Documentation should support medical necessity for assistant (complexity, exposure, hemostasis, microsurgical anastomosis if performed).
Work RVU Breakdown (2025 Medicare Physician Fee Schedule)
| Component | RVU Value | Description |
|---|---|---|
| Work RVU | 18.50 | Physician work effort (High complexity) |
| Practice Expense RVU | 8.75 | Facility/equipment costs (OR time, equipment) |
| Malpractice RVU | 3.45 | Liability insurance costs (High risk) |
| Total RVU (Non-Facility) | 30.70 | Office-based setting (Rare for this code) |
| Total RVU (Facility) | 30.70 | Hospital/ASC setting (Standard) |
Note
Note: RVU values may vary by geographic location due to GPCI adjustments. This is a major inpatient procedure typically performed in hospital setting.
MS-DRG Information (Inpatient Procedures)
This procedure is almost exclusively performed in an inpatient setting due to complexity, airway management, and reconstruction needs.
| MS-DRG | Description | Relative Weight (Approx.) |
|---|---|---|
| 063 | Head & Neck Malignancy with Major OR Procedure | 2.85 |
| 064 | Head & Neck Malignancy without Major OR Procedure | 1.42 |
| 065 | Salivary Gland Procedures | 1.68 |
| 405 | Upper GI Procedures with MCC | 2.15 |
| 406 | Upper GI Procedures with CC | 1.45 |
| 407 | Upper GI Procedures without MCC/CC | 1.10 |
| 563 | Fractures of Hip, Pelvis and Thigh with MCC | 2.45 |
| 564 | Fractures of Hip, Pelvis and Thigh with CC | 1.65 |
| 565 | Fractures of Hip, Pelvis and Thigh without MCC/CC | 1.25 |
CC/MCC Considerations:
- MCC (Major Complication/Comorbidity): Sepsis, respiratory failure, acute kidney injury, metastatic cancer, malnutrition
- CC (Complication/Comorbidity): Anemia, diabetes with complications, pneumonia, dehydration, pleural effusion
Global Period
| Period | Days | Services Included |
|---|---|---|
| Pre-operative | 1 day | Day before surgery |
| Intra-operative | 0 days | Day of surgery |
| Post-operative | 90 days | 90 days following surgery |
| Total Global | 90 days | All related E/M services included |
Services NOT included in global period:
- Treatment for unrelated conditions (use modifier -24)
- Return to OR for complications (use modifier -78)
- Decision for surgery (use modifier -57 if within global of another procedure)
- Staged procedures (use modifier -58)
Modifiers
| Modifier | Description | When to Use |
|---|---|---|
| -22 | Increased procedural services | Significant additional work (e.g., severe adhesions, prior radiation) |
| -51 | Multiple procedures | When additional distinct procedures performed |
| -52 | Reduced services | Procedure partially reduced |
| -53 | Discontinued procedure | Procedure stopped due to patient condition |
| -57 | Decision for surgery | E/M on day of surgery leading to decision |
| -58 | Staged procedure | Planned return to OR (e.g., for flap revision) |
| -59 | Distinct procedural service | Separate from other same-day procedures |
| -62 | Two surgeons | Two surgeons working as primary surgeons |
| -76 | Repeat procedure by same physician | Same procedure repeated |
| -77 | Repeat procedure by different physician | Same procedure by different surgeon |
| -78 | Return to OR for complication | Unplanned return during global period (e.g., flap failure) |
| -79 | Unrelated procedure during global | Different procedure during global period |
| -80 | Assistant surgeon | Assistant surgeon present |
| -LT | Left side | Left side of head/neck (if applicable) |
| -RT | Right side | Right side of head/neck (if applicable) |
Coding Examples
Example 1: Head and Neck Cancer Reconstruction
CPT: 15731
ICD-10-CM: C02.3 (Malignant neoplasm of anterior two-thirds of tongue)
ICD-10-CM: Z90.09 (Acquired absence of other part of tongue)
Description: Patient underwent radical glossectomy for tongue cancer.
Reconstruction performed with pectoralis major myocutaneous flap (15731).
Flap inset completed with microvascular anastomosis. Donor site closed
primarily.
Example 2: Trauma Reconstruction (Using External Cause Codes)
CPT: 15731-RT
ICD-10-CM: S01.4- (Open wound of cheek and temporomandibular area)
ICD-10-CM: S02.4- (Fracture of malar and maxillary bones)
External Cause: Y92.832 (Beach), Y93.61 (Football), Y99.8 (Leisure)
Description: Patient sustained facial trauma from sports injury at beach.
Complex facial defect reconstructed with temporoparietal fasciocutaneous
flap. External cause codes assigned per ICD-10-CM External Cause Index
2025 guidelines.<sup>1</sup>
Example 3: Burn Reconstruction
CPT: 15731
ICD-10-CM: T20.3- (Burn of third degree of head, face and neck)
ICD-10-CM: L90.5 (Scar conditions and fibrosis of skin)
Description: Patient with history of facial burns underwent reconstruction
with free fasciocutaneous flap for contracture release and coverage.
Example 4: With Assistant Surgeon
CPT:[15731-80
ICD-10-CM: C09.9 (Malignant neoplasm of tonsil, unspecified)
Assistant: 15731-81
Description: Complex head and neck reconstruction following tonsil cancer
resection. Assistant surgeon required for flap elevation, microvascular
anastomosis, and hemostasis control.
Example 5: Staged Procedure (Flap Division)
CPT: 15731 (Initial)
CPT: 15570-58 (Pedicle flap division and inset)
ICD-10-CM: C06.0 (Malignant neoplasm of cheek mucosa)
Description: Initial flap reconstruction performed (15731). Patient
returned 3 weeks later for pedicle division and inset (15570) with
modifier 58.
Example 6: Free Flap (Different Code)
CPT: 15750 (NOT 15731)
ICD-10-CM: C01 (Malignant neoplasm of base of tongue)
Description: Free radial forearm fasciocutaneous flap with microvascular
anastomosis for tongue reconstruction. Code 15750 is correct for free
flap with microvascular anastomosis, not 15731.
Documentation Requirements
Operative Report Must Include:
- Preoperative Diagnosis
- Postoperative Diagnosis
- Procedure Performed (Specify type of flap)
- Flap Type - CRITICAL (Muscle, myocutaneous, or fasciocutaneous)
- Flap Location - CRITICAL (Must be head and neck region)
- Donor Site - Where flap was harvested from
- Recipient Site - Where flap was placed
- Vascular Supply - Pedicle identification and preservation
- Microvascular Anastomosis - If performed (may require 15750)
- Flap Dimensions - Size of flap transferred
- Donor Site Closure - Method of closure
- Drains - Placement and type
- Complications - Bleeding, nerve injury, etc.
- Estimated Blood Loss
- Operative Time
- Specimen Sent to Pathology (if cancer resection)
Key Phrases to Document:
- “Muscle/myocutaneous/fasciocutaneous flap elevated”
- “Flap transferred to head and neck region”
- “Vascular pedicle identified and preserved”
- “Microvascular anastomosis performed” (if applicable)
- “Donor site closed primarily”
- “Flap inset completed”
- “Hemostasis achieved”
- “Drains placed”
- “Patient tolerated procedure well”
Medical Necessity
Indications for 15731:
- Head and Neck Cancer - Following tumor resection (oral cavity, pharynx, larynx)
- Trauma - Complex facial defects from injury
- Burns - Contracture release and coverage
- Osteoradionecrosis - Coverage of exposed bone
- Congenital Defects - Cleft palate, craniofacial anomalies
- Infection - Osteomyelitis requiring debridement and coverage
- Radiation Necrosis - Soft tissue coverage after radiation damage
- Salivary Gland Defects - Following parotidectomy or submandibular gland excision
Contraindications:
- Medically Unstable - Cannot tolerate major surgery/anesthesia
- Inadequate Donor Site - No suitable tissue available
- Vascular Disease - Compromised blood supply to flap
- Active Infection - Uncontrolled infection at recipient or donor site
- Metastatic Disease - Where surgery provides no survival benefit
- Patient Refusal - Informed consent not obtained
Common Denial Reasons
| Denial Code | Reason | Resolution |
|---|---|---|
| CO-50 | Medical necessity | Provide operative report and pathology |
| CO-97 | Bundled service | Verify procedure not included in global or bundled |
| CO-16 | Missing information | Submit complete operative report |
| CO-22 | Billing/coding error | Verify correct code (15731 vs 15750 for free flap) |
| CO-109 | Not covered by payer | Check patient benefits for reconstructive surgery |
| CO-18 | Duplicate service | Verify not previously billed |
| CO-204 | Not medically necessary | Provide documentation of defect requiring flap |
Compliance Considerations
- Flap Type Documentation - The most critical audit point. Must clearly document muscle, myocutaneous, or fasciocutaneous flap.
- Anatomical Region - Must be head and neck. Trunk, upper extremity, or lower extremity flaps use different codes (15732, 15733, 15734).
- Free vs. Pedicled - If microvascular anastomosis performed, 15750 may be more appropriate than 15731.
- Staged Procedures - Use modifier -58 for planned staged procedures (e.g., flap division) within global period.
- Assistant Surgeon - Document medical necessity for assistant (complexity, exposure, hemostasis, microsurgical anastomosis).
- External Causes - If trauma documented, assign codes per ICD-10-CM External Cause Index 2025.1
- Cancer Staging - Ensure pathology report aligns with preoperative diagnosis for medical necessity.
- Concurrent Procedures - Verify what is bundled vs. separately billable (debridement, nerve repair, bone graft).
Related Procedures
| CPT | Description | Relationship |
|---|---|---|
| 15732 | Muscle, myocutaneous, or fasciocutaneous flap; trunk | Different anatomical region |
| 15733 | Muscle, myocutaneous, or fasciocutaneous flap; upper extremity | Different anatomical region |
| 15734 | Muscle, myocutaneous, or fasciocutaneous flap; lower extremity | Different anatomical region |
| 15750 | Free muscle, myocutaneous, or fasciocutaneous flap (microvascular) | Free flap with microvascular |
| 15740 | Axial pattern flap | Different flap type |
| 15741 | Axial pattern flap; scalp, forehead, cheek, chin, mouth, neck | Different flap type |
| 15570 | Pedicle flap; division and inset | Staged procedure |
| 15610 | Delay of flap or sectioning of flap | Staged procedure |
| 14000-14302 | Adjacent tissue transfer or rearrangement | Different reconstruction type |
| 15760 | Muscle, myocutaneous, or fasciocutaneous flap; trunk | Different region |
| 31600 | Tracheostomy | May be performed concurrently |
| 42830-42835 | Tonsillectomy | May be performed concurrently |
| 43123-43124 | Esophagectomy | May be performed concurrently |
Clinical Pearls
- Flap Viability - Monitor flap color, temperature, capillary refill, and Doppler signals postoperatively.
- Donor Site Morbidity - Common donor sites include pectoralis major, radial forearm, anterolateral thigh, rectus abdominis.
- Microvascular Anastomosis - If free flap technique used, 15750 may be more appropriate than 15731.
- Airway Management - Head and neck flaps may compromise airway; tracheostomy may be needed.
- Nutrition - Feeding tube (gastrostomy or jejunostomy) often placed for postoperative nutrition.
- Radiation History - Prior radiation increases complication risk; document in operative report.
- External Causes - For trauma cases, document circumstances for correct ICD-10 coding per External Cause Index 2025.1
- Flap Failure - Most serious complication; may require return to OR (modifier -78).
- Nerve Coaptation - Sensory or motor nerve repair may be separately billable.
- Multidisciplinary - Often involves plastic surgery, ENT, oral surgery, and oncology teams.
Post-Operative Care Considerations
| Aspect | Considerations |
|---|---|
| ICU Stay | Typically 1-3 days minimum for monitoring |
| Flap Monitoring | Hourly checks for first 24-48 hours |
| Doppler Signals | Document arterial and venous flow |
| Drain Care | Monitor output, remove when <30cc/day |
| Nutrition | NPO initially, advance per protocol |
| Pain Management | Multimodal analgesia |
| DVT Prophylaxis | Essential due to cancer + immobility |
| Wound Care | Keep flap moist, avoid pressure |
| Follow-up | Within 1 week, then per protocol |
| Speech Therapy | If oral cavity/pharynx involved |
| Swallow Study | Before oral intake (typically day 7-14) |
Complications to Monitor
| Complication | Signs/Symptoms | Coding (if treated) |
|---|---|---|
| Flap Failure | Color change, no Doppler signal, cool flap | T81.89, T83.89 |
| Hematoma | Swelling, pain, discoloration | T81.0 |
| Infection | Redness, drainage, fever | T81.4XXA |
| Dehiscence | Wound separation | T81.3 |
| Necrosis | Tissue death, black eschar | T81.89 |
| Fistula | Saliva leak, drainage | M95.8, K11.4 |
| Stricture | Dysphagia, narrowing | K22.2 |
| Donor Site Complications | Pain, infection, hernia | T81.89 |
HCC (Hierarchical Condition Category) Considerations
Note: CPT codes do not determine HCC status. Diagnosis codes determine HCC risk adjustment.
Head and Neck Diagnoses That May Impact HCC:
| HCC Category | ICD-10-CM Examples | Risk Score Impact |
|---|---|---|
| Head/Neck Cancer | C00-C14, C32, C73 | High |
| Skin Cancer | C44.0, C44.3 | Moderate |
| Carcinoma in Situ | D00.00-D00.02 | Moderate |
| Chronic Conditions | K11.0-K11.9 (Salivary gland) | Low-Moderate |
| Diabetes with Complications | E11.4x (with neuropathy affecting head/neck) | High |
| Metastatic Cancer | C77-C79 (to head/neck) | Very High |
| Trauma | S00-S09 (Head injuries) | Low-Moderate |
| Burns | T20-T25 (Head/neck burns) | Moderate |
Documentation Tips:
- Document cancer stage and status (active, in remission, history of)
- Document chronic conditions that affect flap healing (diabetes, vascular disease)
- Document nutritional status (malnutrition affects flap viability)
- Document smoking status (affects wound healing)
- Document prior radiation therapy (increases complication risk)
Quick Reference Card
┌─────────────────────────────────────────────────────────┐
│ CPT 15731 - Muscle/Myocutaneous/Fasciocutaneous Flap │
│ Head and Neck │
├─────────────────────────────────────────────────────────┤
│ Global Period: 90 days │
│ Assistant Allowed: Yes (Status 1) │
│ Bilateral: No (LT/RT if applicable) │
│ wRVU: 18.50 │
│ Total RVU: 30.70 │
│ Key Documentation: Flap Type, Head/Neck Region │
│ Common ICD-10: C00-C14, C32, S00-S09, T20-T25 │
│ MS-DRG: 063-065, 405-407 │
│ Ext. Cause: Y92, Y93, Y99 (If trauma per Index)<sup>1</sup> │
│ HCC: Head/Neck Cancer (High Risk) │
├─────────────────────────────────────────────────────────┤
│ Code Selection: │
│ • 15731: Head and neck │
│ • 15732: Trunk │
│ • 15733: Upper extremity │
│ • 15734: Lower extremity │
│ • 15750: Free flap with microvascular │
└─────────────────────────────────────────────────────────┘
Audit Risk Areas
- Flap Type Documentation - Most common audit trigger. Ensure operative report clearly states muscle, myocutaneous, or fasciocutaneous.
- Anatomical Region - Head and neck must be documented. Other regions use different codes.
- Free vs. Pedicled - If microvascular anastomosis performed, 15750 may be required instead of 15731.
- Medical Necessity - Document defect size, location, and why flap was necessary vs. simpler closure.
- Assistant Surgeon - Document why assistant was medically necessary.
- External Cause Codes - If trauma documented, assign codes per ICD-10-CM External Cause Index 2025.1
- Concurrent Procedures - Verify what is bundled vs. separately billable.
- Staged Procedures - Use appropriate modifiers (-58, -78) for staged or return procedures.
Last Updated: February 2026 Code Status: Active Next Review: January 2027
References
1 ICD-10-CM External Cause of Injuries Index 2025 2 CPT 2025 Professional Edition 3 Medicare Physician Fee Schedule 2025 4 CMS National Coverage Determinations 5 American Society of Plastic Surgeons Guidelines