Integumentary- Other Procedures

 

 

 

CPT CODE -15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)

1. • PT code 15780 is used for dermabrasion procedures on the total face.
   • The procedure is typically performed for conditions such as acne scarring, fine wrinkling, rhytids (wrinkles), and general keratosis (thickened or rough skin).
2. Procedure Description:
   • This code is applicable when dermabrasion is performed on the entire face, addressing various skin conditions.
3. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Specify the reason for dermabrasion (e.g., acne scarring, fine wrinkling, rhytids, general keratosis), the extent of the procedure (total face), and any specific conditions or complications.

Example:

Scenario: A patient seeks cosmetic improvement for facial skin concerns, including acne scarring, fine wrinkling, and general keratosis. The dermatologist performs dermabrasion on the entire face.

Code Assignment:

• CPT Code: 15780
• Description: Dermabrasion; total face (e.g., for acne scarring, fine wrinkling, rhytids, general keratosis).

Documentation: The medical record should include the following information:

• Reason for dermabrasion (e.g., acne scarring, fine wrinkling, general keratosis)
• Confirmation that the dermabrasion was performed on the total face
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the total face dermabrasion procedure described by CPT code 15780.

 

CPT CODE – 15781 Dermabrasion; segmental, face

CPT CODE – 15782 Dermabrasion; regional, other than face

CPT CODE – 15783 Dermabrasion; superficial, any site (eg, tattoo removal)

CPT CODE – 15786 Abrasion; single lesion (eg, keratosis, scar)

CPT code 15786 is used for abrasion procedures on a single lesion.

1. The procedure is typically performed for specific lesions such as keratosis or scars.
2. Procedure Description:
   • This code is applicable when abrasion is performed on a single lesion, targeting a specific area of concern.
3. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Specify the reason for the abrasion (e.g., keratosis, scar), identify the specific lesion, and document any specific conditions or complications.

Example:

Scenario: A patient presents with a raised and bothersome scar on the forearm. The dermatologist performs an abrasion procedure to address and smooth out the scar.

Code Assignment:

• CPT Code: 15786
• Description: Abrasion; single lesion (e.g., keratosis, scar).

Documentation: The medical record should include the following information:

• Reason for abrasion (e.g., scar)
• Identification of the specific lesion (e.g., location on the forearm)
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the single lesion abrasion procedure described by CPT code 15786.

CPT CODE – ✚ 15787 Abrasion; each additional 4 lesions or less (List separately in addition to code for primary procedure)
(Use 15787 in conjunction with 15786)

CPT CODE – 15788 Chemical peel, facial; epidermal

1. CPT code 15788 is used for chemical peel procedures specifically targeting the epidermis of the face.
2. • The procedure involves the application of a chemical solution to the facial skin to achieve exfoliation and improve skin appearance.
3. Procedure Description:
   • This code is applicable when a chemical peel is performed on the facial skin, specifically targeting the epidermis.
   • Chemical peels are commonly used for cosmetic purposes to address issues such as wrinkles, sun damage, or uneven pigmentation.
4. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Specify that the chemical peel is focused on the facial area and targets the epidermis. Document any specific conditions or complications.

Example:

Scenario: A patient seeks a cosmetic procedure to address fine lines and uneven skin tone on the face. The dermatologist performs a chemical peel using a solution that targets the epidermis of the facial skin.

Code Assignment:

• CPT Code: 15788
• Description: Chemical peel, facial; epidermal.

Documentation: The medical record should include the following information:

• Reason for the chemical peel (e.g., fine lines, uneven skin tone)
• Confirmation that the chemical peel is focused on the facial area
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the chemical peel procedure targeting the epidermis described by CPT code 15788

 

CPT CODE – 15789 Chemical peel, facial;  dermal

CPT CODE – 15792 Chemical peel, nonfacial; epidermal

1. • CPT code 15792 is used for chemical peel procedures that target the epidermis, specifically for nonfacial areas.
   • The procedure involves the application of a chemical solution to the skin outside of the facial region to achieve exfoliation and improve skin appearance.
2. Procedure Description:
   • This code is applicable when a chemical peel is performed on areas other than the face, specifically targeting the epidermis.
   • Chemical peels are commonly used for cosmetic purposes to address issues such as uneven pigmentation, sun damage, or other skin concerns in nonfacial regions.
3. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Specify that the chemical peel is focused on nonfacial areas and targets the epidermis. Document any specific conditions or complications.

Example:

Scenario: A patient seeks a cosmetic procedure to address sun damage on the hands. The dermatologist performs a chemical peel using a solution that targets the epidermis of the hands.

Code Assignment:

• CPT Code: 15792
• Description: Chemical peel, nonfacial; epidermal.

Documentation: The medical record should include the following information:

• Reason for the chemical peel (e.g., sun damage on the hands)
• Confirmation that the chemical peel is focused on nonfacial areas
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the chemical peel procedure targeting the epidermis in nonfacial areas described by CPT code 15792.

CPT CODE – 15793 Chemical peel, nonfacial; dermal

CPT CODE – 15819 Cervicoplasty

CPT code 15819 is used for cervicoplasty, a surgical procedure aimed at modifying and improving the contour and appearance of the neck. Here are coding guidelines and an example for CPT code 15819:

Coding Guidelines for CPT Code 15819:

1. Definition of the Code:
   • CPT code 15819 is specifically designated for cervicoplasty.
   • Cervicoplasty involves the surgical modification or reconstruction of the neck area to enhance its contour and appearance.
2. Procedure Description:
   • This code is applicable when the surgical procedure focuses on addressing excess or sagging skin in the neck region.
   • Cervicoplasty is often performed as part of a more comprehensive approach to neck rejuvenation or facelift procedures.
3. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Specify the details of the cervicoplasty procedure, including the extent of tissue removal or modification and any other concurrent procedures. Document any specific conditions or complications.

Example:

Scenario: A patient seeks cosmetic improvement for sagging skin in the neck area. The plastic surgeon performs a cervicoplasty procedure to tighten and reshape the neck.

Code Assignment:

• CPT Code: 15819
• Description: Cervicoplasty.

Documentation: The medical record should include the following information:

• Reason for cervicoplasty (e.g., sagging skin in the neck)
• Details of the cervicoplasty procedure, including the extent of tissue modification
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the cervicoplasty procedure described by CPT code 15819.

CPT CODE – 15820 Blepharoplasty, lower eyelid;

CPT code 15820 is used for lower eyelid blepharoplasty, a surgical procedure aimed at modifying and improving the appearance of the lower eyelid. Here are coding guidelines and an example for CPT code 15820:

Coding Guidelines for CPT Code 15820:

1. Definition of the Code:
   • CPT code 15820 is specifically designated for lower eyelid blepharoplasty.
   • Blepharoplasty involves the surgical modification or reconstruction of the eyelid to improve its appearance.
2. Procedure Description:
   • This code is applicable when the surgical procedure focuses on modifying the lower eyelid to address issues such as excess skin, fat, or sagging.
3. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Specify the details of the lower eyelid blepharoplasty procedure, including any tissue removal, fat repositioning, or other techniques used to enhance the lower eyelid’s appearance. Document any specific conditions or complications.

Example:

Scenario: A patient presents with concerns about excess skin and puffiness in the lower eyelids, affecting their appearance. The plastic surgeon performs a lower eyelid blepharoplasty to address these concerns.

Code Assignment:

• CPT Code: 15820
• Description: Blepharoplasty, lower eyelid.

Documentation: The medical record should include the following information:

• Reason for lower eyelid blepharoplasty (e.g., excess skin, puffiness)
• Details of the blepharoplasty procedure, including any tissue modification or repositioning
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the lower eyelid blepharoplasty procedure described by CPT code 15820.

CPT CODE – 15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad

CPT CODE – 15822 Blepharoplasty, upper eyelid;

CPT code 15822 is used for upper eyelid blepharoplasty, a surgical procedure aimed at modifying and improving the appearance of the upper eyelid. Here are coding guidelines and an example for CPT code 15822:

Coding Guidelines for CPT Code 15822:

1. Definition of the Code:
   • CPT code 15822 is specifically designated for upper eyelid blepharoplasty.
   • Blepharoplasty involves the surgical modification or reconstruction of the eyelid to improve its appearance.
2. Procedure Description:
   • This code is applicable when the surgical procedure focuses on modifying the upper eyelid to address issues such as excess skin, fat, or sagging.
3. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Specify the details of the upper eyelid blepharoplasty procedure, including any tissue removal, fat repositioning, or other techniques used to enhance the upper eyelid’s appearance. Document any specific conditions or complications.

Example:

Scenario: A patient presents with concerns about hooding and excess skin on the upper eyelids, affecting their appearance. The plastic surgeon performs an upper eyelid blepharoplasty to address these concerns.

Code Assignment:

• CPT Code: 15822
• Description: Blepharoplasty, upper eyelid.

Documentation: The medical record should include the following information:

• Reason for upper eyelid blepharoplasty (e.g., hooding, excess skin)
• Details of the blepharoplasty procedure, including any tissue modification or repositioning
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the upper eyelid blepharoplasty procedure described by CPT code 15822.

 

CPT CODE – 15823 Blepharoplasty, upper eyelid; with excessive skin weighting down the lid
(For bilateral blepharoplasty, add modifier 50)

CPT CODE – 15824 Rhytidectomy; forehead
(For repair of brow ptosis, use 67900)

 

1. • CPT code 15824 is specifically designated for a rhytidectomy (forehead lift).
   • Rhytidectomy involves the surgical modification or reconstruction of the forehead to improve its appearance by addressing wrinkles, sagging, or other aging-related changes.
2. Procedure Description:
   • This code is applicable when the surgical procedure focuses on modifying the forehead to achieve a more youthful and rejuvenated appearance.
3. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Specify the details of the forehead rhytidectomy procedure, including the techniques used (e.g., endoscopic or open), the extent of tissue modification, and any other concurrent procedures. Document any specific conditions or complications.

Example:

Scenario: A patient seeks cosmetic improvement for deep wrinkles and sagging in the forehead area. The plastic surgeon performs a forehead rhytidectomy to address these concerns.

Code Assignment:

• CPT Code: 15824
• Description: Rhytidectomy; forehead.

Documentation: The medical record should include the following information:

• Reason for the forehead rhytidectomy (e.g., deep wrinkles, sagging)
• Details of the rhytidectomy procedure, including the techniques used
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the forehead rhytidectomy procedure described by CPT code 15824.

 

CPT CODE – 15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)

CPT CODE – 15826 Rhytidectomy; glabellar frown lines

CPT CODE – 15828 Rhytidectomy; cheek, chin, and neck

CPT CODE – 15829 Rhytidectomy;  superficial musculoaponeurotic system (SMAS) flap
(For bilateral rhytidectomy, add modifier 50)

CPT CODE – 15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infra umbilical panniculectomy
(Do not report 15830 in conjunction with 12031-12037, 13100-13102, 14000, 14001, or 14302 for the same wound)

 

PT code 15830 is used for an infra umbilical panniculectomy, which involves the excision of excessive skin and subcutaneous tissue in the lower abdomen. Here are coding guidelines and an example for CPT code 15830:

Coding Guidelines for CPT Code 15830:

1. Definition of the Code:
   • CPT code 15830 is specifically designated for infraumbilical panniculectomy.
   • Panniculectomy involves the surgical removal of excessive skin and subcutaneous tissue, particularly in the lower abdominal area.
2. Procedure Description:
   • This code is applicable when the surgical procedure focuses on excising excess skin and subcutaneous tissue below the umbilicus (belly button).
3. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Specify the reason for the panniculectomy, the extent of tissue removal, and any other concurrent procedures. Document any specific conditions or complications.

Example:

Scenario: A patient, after significant weight loss, has excessive skin and tissue in the lower abdomen causing discomfort and hygiene issues. The plastic surgeon performs an infra umbilical panniculectomy to address these concerns.

Code Assignment:

• CPT Code: 15830
• Description: Excision, excessive skin, and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy.

Documentation: The medical record should include the following information:

• Reason for infraumbilical panniculectomy (e.g., excessive skin after weight loss)
• Details of the excision procedure, including the extent of tissue removal
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the infraumbilical panniculectomy procedure described by CPT code 15830.

 

CPT CODE – 15832 Excision, excessive skin, and subcutaneous tissue (includes lipectomy);  thigh

CPT CODE -15833 Excision, excessive skin, and subcutaneous tissue (includes lipectomy);  leg

CPT CODE – 15834Excision, excessive skin and subcutaneous tissue (includes lipectomy);  hip

CPT CODE – 15835 Excision, excessive skin and subcutaneous tissue (includes lipectomy);  buttock

CPT CODE – 15836 Excision, excessive skin, and subcutaneous tissue (includes lipectomy);  arm

CPT CODE – 15837 Excision, excessive skin and subcutaneous tissue (includes lipectomy);  forearm or hand

CPT CODE – 15838 Excision, excessive skin and subcutaneous tissue (includes lipectomy);  submental fat pad

CPT CODE – 15839 Excision, excessive skin, and subcutaneous tissue (includes lipectomy);  other area
(For bilateral procedure, add modifier 50)

CPT CODE – 15840 Graft for facial nerve paralysis; free fascia graft
(including obtaining fascia)
(For bilateral procedure, add modifier 50)

 

CPT code 15840 is used for a graft procedure for facial nerve paralysis, specifically involving a free fascia graft. Here are coding guidelines and an example for CPT code 15840:

Coding Guidelines for CPT Code 15840:

1. Definition of the Code:
   • CPT code 15840 is designated for a graft procedure to address facial nerve paralysis.
   • The code specifies the use of a free fascia graft.
2. Procedure Description:
   • This code is applicable when the surgical procedure involves the grafting of free fascia to address facial nerve paralysis.
3. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Specify the reason for the graft procedure, the use of a free fascia graft, and any other details regarding the surgical technique. Document any specific conditions or complications.

Example:

Scenario: A patient presents with facial nerve paralysis, causing asymmetry and functional issues. The plastic surgeon performs a graft procedure using a free fascia graft to restore facial symmetry and function.

Code Assignment:

• CPT Code: 15840
• Description: Graft for facial nerve paralysis; free fascia graft.

Documentation: The medical record should include the following information:

• Reason for the graft procedure (facial nerve paralysis)
• Use of a free fascia graft
• Details of the grafting procedure
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the facial nerve paralysis graft procedure using a free fascia graft described by CPT code 15840.

 

CPT CODE – 15841 Graft for facial nerve paralysis; free muscle graft (including obtaining graft)

CPT CODE – 15842 Graft for facial nerve paralysis; free muscle flap by microsurgical technique
(Do not report code 69990 in addition to code 15842)

CPT CODE – 15845 Graft for facial nerve paralysis; regional muscle transfer
(For intravenous fluorescein examination of blood flow in graft or flap, use 15860)
(For nerve transfers, decompression, or repair, see 64831- 64876, 64905, 64907, 69720, 69725, 69740, 69745, 69955)

CPT CODE – ✚ 15847 Graft for facial nerve paralysis; Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)
(Use 15847 in conjunction with 15830)
(For abdominal wall hernia repair, see 49491-49587)
(To report other abdominoplasty, use 17999)

CPT Code 15850 Removal of sutures under anesthesia (other than local),
same surgeon

CPT CODE – 15851 Removal of sutures under anesthesia (other than local), other surgeon

 

1. CPT code 15851 is designated for the removal of sutures under anesthesia.
2. • The code specifies that the removal is performed by a surgeon other than the one who initially placed the sutures.
3. Procedure Description:
   • This code is applicable when the removal of sutures is performed under anesthesia, and a different surgeon performs the removal than the one who placed the sutures.
4. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Specify the reason for the removal under anesthesia, the type of anesthesia used, and the identity of the surgeon performing the removal. Document any specific conditions or complications.

Example:

Scenario: A patient had surgery with sutures placed by Surgeon A. However, due to the patient’s pain tolerance or other medical considerations, Surgeon B performs the removal of sutures under anesthesia.

Code Assignment:

• CPT Code: 15851
• Description: Removal of sutures under anesthesia (other than local), by other surgeons.

Documentation: The medical record should include the following information:

• Reason for removal under anesthesia
• Type of anesthesia used
• Identification of the surgeon performing the removal (Surgeon B)
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the removal of sutures under anesthesia performed by a surgeon other than the one who placed the sutures, described by CPT code 15851.

 

CPT CODE – 15852 Dressing change (for other than burns) under anesthesia (other than local)

1. CPT code 15852 is designated for dressing changes under anesthesia, excluding burns.
2. • The code specifies that the dressing change is performed under anesthesia other than local anesthesia.
3. Procedure Description:
   • This code is applicable when a dressing change procedure is performed under anesthesia for conditions other than burns.
4. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Specify the reason for the dressing change under anesthesia, the type of anesthesia used, and any relevant details regarding the dressing change procedure. Document any specific conditions or complications.

Example:

Scenario: A patient has a complex wound or surgical site that requires dressing changes, but the patient cannot tolerate the procedure without anesthesia. The healthcare provider performs the dressing change under general anesthesia.

Code Assignment:

• CPT Code: 15852
• Description: Dressing change (for other than burns) under anesthesia (other than local).

Documentation: The medical record should include the following information:

• Reason for the dressing change under anesthesia
• Type of anesthesia used (other than local)
• Any relevant details regarding the dressing change procedure
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the dressing change under anesthesia for conditions other than burns, described by CPT code 15852.

 

CPT CODE – 15860 Intravenous injections of agent (eg, fluorescein) to test vascular flow in flap or graft

CPT code 15860 is used for the intravenous injection of an agent, such as fluorescein, to test vascular flow in a flap or graft. Here are coding guidelines and an example for CPT code 15860:

Coding Guidelines for CPT Code 15860:

1. Definition of the Code:
   • CPT code 15860 is designated for the intravenous injection of an agent, such as fluorescein, specifically used to test vascular flow in a flap or graft.
2. Procedure Description:
   • This code is applicable when the healthcare provider performs an intravenous injection of a vascular flow testing agent for a flap or graft.
3. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Specify the reason for the vascular flow testing, the type of agent injected (e.g., fluorescein), and any relevant details regarding the procedure. Document any specific conditions or complications.

Example:

Scenario: A patient has undergone reconstructive surgery involving a flap or graft. To assess the vascular flow in the newly created tissue, the healthcare provider performs an intravenous injection of fluorescein.

Code Assignment:

• CPT Code: 15860
• Description: Intravenous injection of agent (e.g., fluorescein) to test vascular flow in flap or graft.

Documentation: The medical record should include the following information:

• Reason for vascular flow testing (assessment of flap or graft)
• Type of agent injected (e.g., fluorescein)
• Any relevant details regarding the vascular flow testing procedure
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the intravenous injection of a vascular flow testing agent for a flap or graft, described by CPT code 15860.

 CPT CODE -15876 Suction assisted lipectomy; head and neck

CPT code 15876 is used for suction-assisted lipectomy (liposuction) specifically performed on the head and neck area. Here are coding guidelines and an example for CPT code 15876:

Coding Guidelines for CPT Code 15876:

1. Definition of the Code:
   • CPT code 15876 is designated for suction-assisted lipectomy (liposuction) on the head and neck.
2. Procedure Description:
   • This code is applicable when the healthcare provider performs liposuction to remove excess fat from the head and neck area using suction-assisted techniques.
3. Documentation Requirements:
   • Adequate documentation is crucial to support the medical necessity of the procedure.
   • Specify the reason for the liposuction procedure, the specific areas treated in the head and neck, and any relevant details regarding the liposuction technique. Document any specific conditions or complications.

Example:

Scenario: A patient is bothered by excess fat deposits in the neck and under the chin. The plastic surgeon performs suction-assisted lipectomy (liposuction) to contour and improve the patient’s profile.

Code Assignment:

• CPT Code: 15876
• Description: Suction-assisted lipectomy; head and neck.

Documentation: The medical record should include the following information:

• Reason for liposuction (excess fat in the head and neck)
• Specific areas treated (head and neck)
• Details of the liposuction procedure, including the technique used
• Any specific conditions or complications

By following these guidelines and providing accurate documentation, you ensure proper coding for the suction-assisted lipectomy on the head and neck described by CPT code 15876.

CPT CODE – 15877 Suction assisted lipectomy; trunk

CPT CODE – 15878 Suction assisted lipectomy; upper extremity

CPT CODE – 15879 Suction assisted lipectomy; lower extremity
(Do not report 15876, 15877, 15878, 15879 in conjunction with 15771, 15772, 15773, 15774, 0489T, 0490T)
(For harvesting of adipose tissue for autologous adipose-derived regenerative cell therapy, use 0489T)
(For autologous fat grafting harvested by liposuction technique, see 15771, 15772, 15773, 15774)

 

Thank you for Visiting to Health Coding Hub

For any queries, please reach out to us at info@healthcodinghub.com