How To Use CPT Code 15839

CPT 15839 refers to the excision of excessive skin and subcutaneous tissue in an unspecified area. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 15839 procedures.

1. What is CPT 15839?

CPT 15839 is a medical billing code used to describe the surgical removal of excessive skin and subcutaneous tissue in an area not specified by other CPT codes. This procedure is typically performed to address issues such as skin redundancy, sagging, or excess fat in areas not covered by other specific codes.

2. 15839 CPT code description

The official description of CPT code 15839 is: “Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area.”

3. Procedure

The CPT 15839 procedure involves the following steps:

1. The patient is prepared for surgery, and the area to be treated is marked and cleaned.
2. Local or general anesthesia is administered to ensure patient comfort during the procedure.
3. The surgeon makes a horizontal incision with a scalpel over the area to be treated.
4. Excess fat is removed using a cannula or hollow needles to suction out the fat, or by direct excision with a scalpel and cautery.
5. Excessive loose skin is excised elliptically using a scalpel and cautery.
6. The incision is closed with sutures, and a dressing is applied to protect the wound.
7. Postoperative care instructions are provided to the patient, and follow-up appointments are scheduled as needed.

4. Qualifying circumstances

Patients eligible to receive CPT 15839 services typically have excessive skin and subcutaneous tissue in an area not specified by other CPT codes. This may be due to factors such as significant weight loss, aging, or genetic predisposition. The patient should have tried conservative measures, such as diet and exercise, without success in addressing the issue. Additionally, the patient should be in good overall health, without any contraindications for surgery, and have realistic expectations about the outcome of the procedure.

5. When to use CPT code 15839

CPT code 15839 should be used when a patient requires surgical removal of excessive skin and subcutaneous tissue in an area not specified by other CPT codes. This may include areas such as the upper arms, inner thighs, or other regions not covered by specific codes. The procedure should be medically necessary and not solely for cosmetic purposes.

6. Documentation requirements

To support a claim for CPT 15839, the following information should be documented:

• Patient’s medical history, including any previous treatments or surgeries related to the issue.
• Physical examination findings, including the extent of excessive skin and subcutaneous tissue in the area to be treated.
• Documentation of conservative measures tried without success, such as diet and exercise.
• Preoperative photographs of the area to be treated, demonstrating the need for the procedure.
• Operative report, including a detailed description of the procedure performed, the amount of tissue removed, and any complications encountered.
• Postoperative photographs and follow-up notes, documenting the patient’s progress and healing.

7. Billing guidelines

When billing for CPT 15839, it is essential to follow the appropriate guidelines and rules. These may include:

• Ensuring that the procedure is medically necessary and not solely for cosmetic purposes.
• Obtaining prior authorization from the patient’s insurance company, if required.
• Using modifier 50 for bilateral procedures, if applicable.
• Accurately documenting the procedure and supporting information, as outlined in the documentation requirements section.
• Reviewing the patient’s insurance policy for any specific coverage limitations or exclusions related to CPT 15839.

8. Historical information

CPT 15839 was added to the Current Procedural Terminology system on January 1, 1990. The code was changed on January 1, 2007, with the previous descriptor being “Excision, excessive skin and subcutaneous tissue (including lipectomy); other area.”

9. Similar codes to CPT 15839

Five similar codes to CPT 15839, which differentiate based on the specific body part being treated, include:

• CPT 15830: Excision of excessive skin and subcutaneous tissue in the face, neck, or infraorbital area.
• CPT 15832: Excision of excessive skin and subcutaneous tissue in the upper arm or thigh.
• CPT 15833: Excision of excessive skin and subcutaneous tissue in the lower leg or ankle.
• CPT 15834: Excision of excessive skin and subcutaneous tissue in the chest or breast.
• CPT 15835: Excision of excessive skin and subcutaneous tissue in the abdomen or flank.

10. Examples

Here are ten detailed examples of CPT code 15839 procedures:

1. Excision of excessive skin and subcutaneous tissue in the upper arms following significant weight loss.
2. Removal of excessive skin and fat in the inner thighs due to aging and skin laxity.
3. Excision of redundant skin and subcutaneous tissue in the lower back after bariatric surgery.
4. Removal of excessive skin and fat in the buttocks due to genetic predisposition.
5. Excision of excessive skin and subcutaneous tissue in the knees following massive weight loss.
6. Removal of redundant skin and fat in the calves due to aging and skin laxity.
7. Excision of excessive skin and subcutaneous tissue in the mons pubis after bariatric surgery.
8. Removal of excessive skin and fat in the axillary region due to genetic predisposition.
9. Excision of redundant skin and subcutaneous tissue in the posterior neck following significant weight loss.
10. Removal of excessive skin and fat in the lateral chest wall due to aging and skin laxity.