Clinical Context
A 42-year-old female seeks autologous fat grafting to correct a persistent contour defect of the lower abdomen following prior abdominoplasty. The surgeon harvests adipose tissue by liposuction from the patient’s flanks, processes the aspirate, and injects up to 50 cc of purified fat into focal depressions of the lower abdominal subcutaneous layer to improve contour and symmetry. The patient arrives to an outpatient surgical center, undergoes preoperative marking and local or general anesthesia per surgeon preference, and receives intraoperative liposuction of a donor site (flanks) followed by fat preparation and microinjection into the recipient site. Postoperative care includes standard wound dressings, activity restrictions, and follow-up visits to assess graft take and wound healing. Typical sites of service are outpatient ambulatory surgical centers or hospital outpatient departments. The service type is an operative autologous fat grafting procedure using liposuction harvest and injection of 50 cc or less into trunk, breast, scalp, arms, or legs, as described by code 15771.
Coding Specifications
| Modifier | Description | When to Use |
|---|
22 | Increased procedural services | Use when work or complexity substantially exceeds the typical service for 15771. |
59 | Distinct procedural service | Use when 15771 is performed in a distinct anatomical site or separate session from other procedures not normally reported together.
62 | Two surgeons | Use when two surgeons work together as primary surgeons performing distinct portions of 15771.
63 | Procedure performed on infants less than 4 kg | Use when applicable for neonatal patients meeting weight criteria.
78 | Return to OR for related procedure during global period | Use if patient returns to the operating room for a complication related to 15771 within the global period.
79 | Unrelated procedure or service by the same physician during the postoperative period | Use when an unrelated procedure is performed during the global period for 15771.
51 | Multiple procedures | Use when 15771 is reported with other procedures during the same session; payer policies may require reduced payment for secondary procedures.
52 | Reduced services | Use when 15771 is partially reduced or not completed at the surgeon’s discretion.
XT is not in the provided list; use only listed modifiers.
QT is not in the provided list; use only listed modifiers.
LT | Left side | Use to identify laterality when the procedure is performed on the left side of a bilateral anatomic area.
RT | Right side | Use to identify laterality when the procedure is performed on the right side of a bilateral anatomic area.
| Taxonomy Code | Specialty | Notes |
|---|
207K00000X | Plastic Surgery | Primary specialty performing autologous fat grafting and contour procedures. |
208600000X | General Surgery | May perform trunk contouring and fat grafting in reconstructive contexts.
2084P0800X | Dermatology | May perform small-volume fat grafting for soft-tissue defects or scar revision.
207P00000X | Oral and Maxillofacial Surgery | Performs fat grafting for facial contour defects and reconstructive needs.
363L00000X | Cosmetic Surgery (subset of Plastic Surgery) | Providers focusing on aesthetic fat grafting to breasts, buttocks, or face.
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|
M22.40 | Chondromalacia, unspecified knee | Data not available in the input. |
L90.5 | Scar conditions and fibrosis of skin | Fat grafting treats depressed or adherent scar defects by adding volume and improving contour.
Z41.1 | Encounter for cosmetic surgery | Used when 15771 is performed for primarily cosmetic purposes.
T81.89 | Other complications of procedures, not elsewhere classified | May be coded if a complication arises that necessitates return to OR or additional treatment after fat grafting.
M21.86 | Other acquired deformity of ankle and foot | Fat grafting can be used for localized contour defects or soft-tissue augmentation in extremities.
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|
15822 | Excision, excessive skin and subcutaneous tissue (e.g., panniculectomy), abdomen, infraumbilical panniculectomy | May be performed before or instead of contouring; sometimes combined in staged abdominal contour procedures. |
19318 | Reduction mammaplasty | Breast-related surgeries where fat grafting (15771) may be used adjunctively for contour refinement.
38531 | Biopsy or excision of lymph node(s); open, deep axillary node dissection | Data not available in the input.
76942 | Ultrasonic guidance for needle placement | May be used to guide fat injection in select deep or intricate recipient sites.
11970 | Flap or graft; adipose tissue transplant, any donor site, including obtaining donor site material — note: 11970 describes non-autologous/adipose grafting in some nomenclature | May be considered in broader autologous tissue transfer workflows but is distinct from 15771 which specifies liposuction-harvested fat injection.