How To Use CPT Code 15828

CPT code 15828 describes a surgical procedure known as rhytidectomy, which involves the removal of excess skin and fat in the cheek, chin, and neck region to tighten the skin. This article will provide a comprehensive overview of CPT code 15828, including its description, official definition, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 15828?

CPT code 15828 is used to describe a surgical procedure called rhytidectomy, commonly known as a facelift. This procedure involves the removal of excess skin and fat in the cheek, chin, and neck region to tighten the skin and reduce the appearance of wrinkles and sagging. It is typically performed under general anesthesia and requires incisions along the natural creases of the face. The surgeon repositions the skin, removes excess tissue, and may tighten underlying muscles if necessary.

2. Official Description

The official description of CPT code 15828 is: ‘Rhytidectomy cheek, chin, and neck.’

3. Procedure

The rhytidectomy procedure begins with the patient being given general anesthesia. The surgeon then makes incisions along the natural creases of the face, such as the cheek, chin, or neck. These incisions allow the surgeon to access the underlying tissues and remove excess skin and fat. If necessary, the surgeon may also tighten the underlying muscles, such as the platysma muscle in the neck. The skin is then repositioned, and any remaining excess skin is excised. The incisions are closed, and drains may be used to remove excess fluid. The entire procedure aims to tighten the skin and reduce the appearance of wrinkles and sagging in the cheek, chin, and neck region.

4. Qualifying circumstances

CPT code 15828 is typically used for patients who desire cosmetic improvement in the cheek, chin, and neck region. It is important to note that this procedure is generally considered cosmetic and may not be covered by insurance unless it is deemed medically necessary. Qualifying circumstances for medical necessity may include severe facial trauma, congenital deformities, or significant functional impairment due to excess skin or fat in the cheek, chin, and neck region. It is essential to obtain preauthorization from the payer if the procedure is determined to be medically necessary.

5. When to use CPT code 15828

CPT code 15828 should be used when a surgeon performs a rhytidectomy procedure specifically targeting the cheek, chin, and neck region. It is important to ensure that the procedure aligns with the official description of the code. If the procedure involves other areas of the face, such as the forehead or glabellar frown lines, different CPT codes should be used (15824 and 15826, respectively). It is crucial to accurately document the areas treated during the procedure to support the use of CPT code 15828.

6. Documentation requirements

Documentation for CPT code 15828 should include the following information:

• Patient’s medical history and reason for seeking the procedure
• Details of the surgical procedure performed, including the specific areas treated (cheek, chin, and neck)
• Incision locations and lengths
• Description of any additional procedures performed, such as muscle tightening or liposuction
• Any complications or unexpected findings during the procedure
• Post-operative care instructions
• Signature of the performing surgeon

7. Billing guidelines

When billing for CPT code 15828, it is important to follow the appropriate billing guidelines. Ensure that the procedure performed aligns with the official description of the code, which is a rhytidectomy of the cheek, chin, and neck. It is crucial to accurately document the areas treated during the procedure to support the use of CPT code 15828. If the procedure involves other areas of the face, different CPT codes should be used. It is also important to verify insurance coverage and obtain preauthorization if the procedure is deemed medically necessary.

8. Historical information

CPT code 15828 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Similar codes to CPT 15828

There are several similar codes to CPT code 15828 that describe other rhytidectomy procedures targeting different areas of the face. These include:

• CPT 15824: Rhytidectomy forehead
• CPT 15825: Rhytidectomy neck with platysmal tightening (platysmal flap, P-flap)
• CPT 15826: Rhytidectomy glabellar frown lines
• CPT 15829: Rhytidectomy superficial musculoaponeurotic system (SMAS) flap

9. Examples

1. A patient undergoes a rhytidectomy procedure to address sagging skin and wrinkles in the cheek, chin, and neck region.
2. A surgeon performs a facelift to tighten the skin and reduce the appearance of aging in the cheek, chin, and neck area.
3. A patient with significant excess skin and fat in the cheek, chin, and neck region undergoes a rhytidectomy for functional improvement.
4. A person seeks a cosmetic improvement in the cheek, chin, and neck area and undergoes a facelift procedure.
5. A surgeon performs a rhytidectomy to address congenital deformities in the cheek, chin, and neck region.
6. A patient with facial trauma undergoes a facelift to repair and tighten the skin in the cheek, chin, and neck area.
7. A person desires a more youthful appearance and undergoes a rhytidectomy to reduce wrinkles and sagging in the cheek, chin, and neck region.
8. A surgeon performs a facelift to improve the contour and definition of the cheek, chin, and neck area.
9. A patient with functional impairment due to excess skin and fat in the cheek, chin, and neck region undergoes a rhytidectomy for medical necessity.
10. An individual seeks a cosmetic enhancement and undergoes a facelift to rejuvenate the cheek, chin, and neck area.