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CPT Code 15830: Excision, Excess Skin and Subcutaneous Tissue; Abdomen, Infraumbilical Panniculectomy

CMS created the Medicare Physician Fee Schedule Look-up Tool for MACs to follow when processing claims. CMS listed CPT code 15830 as a restricted code. Please read the CMS definition for R coverage directly below:

Restricted Coverage: Special coverage instructions apply. If covered, the service is carrier priced. The R indicator is assigned to a limited number of CPT codes which represent services that are covered only in unusual circumstances.

Panniculectomy is removal of panniculus. Panniculus is a medical term describing a dense layer of growth, consisting of subcutaneous fat in the lower abdominal area. It can be a result of obesity and can be mistaken for a tumor or hernia. Abdominal panniculus can be removed during abdominal panniculectomy, a type of abdominoplasty. A panniculus can also be the result of loose tissues after pregnancy or massive weight loss.

Abdominoplasty is usually a cosmetic surgery procedure used to make the abdomen thinner and more firm. The surgery involves the removal of excess skin and fat from the middle and lower abdomen in order to tighten the muscle and fascia of the abdominal wall. This type of surgery is usually sought by patients with loose or sagging tissues after pregnancy or major weight loss. Medicare does not cover cosmetic surgery. It is not part of the Medicare benefit package.

In the publication, CPT 2007 Changes - an Insider's View, the rationale and clinical example are listed on page 33 for reference when this new code was added to CPT.  

Rationale

CPT code 15830 was established to report procedures commonly performed with a procedure referred to as a panniculectomy to prevent the occurrence of recurring rashes, skin maceration, and yeast infections that develop in the abdominopelvic fold following extreme weight loss. That is one reason this is an R status code on the database. If the patient has a sign or symptom it may possibly be a covered benefit. The documentation must show the procedure is performed for a specific problem that the patient presents to the physician.

CPT Code 15830: Excision, Excess Skin and Subcutaneous Tissue; Abdomen, Infraumbilical Panniculectomy
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