Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 15733 billed for date of service April 22,
2021.

You asked the Plan to pay for procedure code 15733. You say that you have provided records to support
payment of 15733. The Plan denied your request. The Plan says the records do not support payment for this
code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 15733 is muscle, myocutaneous, or fasciocutaneous flap
of the head and neck with named vascular pedicle (buccinators, genioglossus, temporalis, masseter,
sternocleidomastoid, levator scapulae).

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the
Plan was correct in denying the request to pay for procedure code 15733. Our reviewer says that procedure
code 15733 is not supported by the medical record. Our reviewer found that the medical records provided do
not include sufficient documentation to verify that a muscle, myocutaneous, or fasciocutaneous flap of the head
and neck with named vascular pedicle (buccinators, genioglossus, temporalis, masseter, sternocleidomastoid,
levator scapulae) was performed on April 22, 2021. The National Correct Coding Initiative Policy Manual for
Medicare Services states the following regarding code 15733: "The physician repairs a defect area using a
muscle, muscle and skin, or a fasciocutaneous flap. The physician rotates the prepared flap from the donor area
to the site needing repair, suturing the flap in place. The donor area is closed primarily with sutures. If a skin
graft or flap is used to repair the donor site, it is considered an additional procedure and is reported separately.
Report 15733 for a muscle, myocutaneous, or fasciocutaneous flap obtained from the head and neck with
named vascular pedicle such as temporalis or sternocleidomastoid; 15734 if obtained from the trunk; 15736 if
obtained from an upper extremity; and 15738 if obtained from a lower extremity. Reporting of a muscle,
myocutaneous, or fasciocutaneous flap differs from that of other flaps as the procedure is always identified by
the donor site when a tube is formed for later transfer or when a flap "delay" occurs prior to transfer but never
by the recipient site. Extensive immobilization and/or repair of the donor site is reported separately. The
vascular pedicles named in the official description of 15733 are the only ones that are applicable to this code.
When 15733 is performed with another separately identifiable procedure, the highest dollar value code is listed
as the primary procedure and subsequent procedures are appended with modifier 51. If significant additional
time and effort is documented, append modifier 22 and submit a cover letter and operative report. For creation
of a midface flap with preservation of the vascular pedicle, see 15730. For creation of a forehead flap with
preservation of the vascular pedicle, see 15731. For repair using non-axial pattern flaps, and/or rearrangement
or adjacent tissue transfer for a head and neck defect, see 14040, 14041, 14060, 14061, 14301, and
14302." This description was not included in the operative note, so code 15733 is not supported.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of procedure code 15733 have not been met. Therefore, we decided that the Plan
does not have to pay for procedure code 15733 billed for date of service April 22, 2021.