A 30-year-old patient with a scalp defect is having plastic surgery to insert tissue expanders. The provider inserts the implants, closes the skin, and increases the volume of the expanders by injecting saline solution. Tissue is expanded until a satisfactory aesthetic outcome is obtained to repair the scalp defect. What CPT® code is reported?

The procedure described is the initial placement of tissue expanders in the scalp to facilitate future repair of a defect. CPT® code 11960, "Insertion of tissue expander(s) for other than breast, including subsequent expansion," accurately captures this service. The code specifies a location "other than breast" (the scalp, in this case) and includes the initial insertion as well as the subsequent injections (e.g., saline) to expand the device, as detailed in the operative note.

B. 11970 describes the replacement of a tissue expander with a permanent prosthesis, which is a subsequent procedure, not the initial insertion.
C. 15777 is for implanting absorbable mesh for delayed closure of defects in specific areas like the abdomen or perineum, not a tissue expander on the scalp.
D. 19357 is specific to breast reconstruction procedures and is anatomically incorrect for a procedure performed on the scalp.

1. American Medical Association (AMA). (2023). CPT® 2024 Professional Edition.

Section: Surgery/Integumentary System

Repair (Closure)

Page/Code: 11960. The code descriptor explicitly states

"Insertion of tissue expander(s) for other than breast

including subsequent expansion." This directly aligns with the described procedure of inserting an expander in the scalp and beginning the expansion process.

Page/Code: 11970

15777

19357. The descriptors for these codes clearly define different procedures

anatomical locations

or types of implants not relevant to the scenario.

2. AAPC. (2023). 2024 CPC® Official Study Guide.

Chapter: Integumentary System

Section: Repair (Closure)

Tissue Expanders. The guide explains that code 11960 is used for the insertion of a tissue expander in any area except the breast and that this code bundles the work of subsequent expansions. This confirms that the saline injection is part of the service described by 11960.