How To Use CPT Code 15838

CPT code 15838 describes the excision of excessive skin and subcutaneous tissue, including lipectomy, of the submental fat pad or double chin. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 15838?

CPT 15838 is used to describe the surgical removal of excessive skin and subcutaneous tissue, including lipectomy, of the submental fat pad or double chin. This procedure is performed to improve the appearance of the neck and jawline by reducing the excess fat and loose skin in the submental area.

2. Official Description

The official description of CPT code 15838 is: ‘Excision, excessive skin and subcutaneous tissue (includes lipectomy) submental fat pad.’

3. Procedure

The procedure for CPT 15838 involves the following steps:

1. The physician makes a horizontal incision with a scalpel over the submental fat pad or double chin area.
2. Excess fat is removed using a cannula or hollow needles through a process called lipectomy.
3. Excessive loose skin is elliptically excised using a scalpel and cautery.

4. Qualifying circumstances

CPT 15838 is typically performed on patients who have excessive submental fat or a double chin that is causing aesthetic concerns. The procedure is suitable for individuals who have tried non-surgical methods, such as diet and exercise, but have not achieved the desired results. It is important to note that the procedure is not intended for weight loss purposes but rather for improving the contour and appearance of the neck and jawline.

5. When to use CPT code 15838

CPT code 15838 should be used when a physician performs the excision of excessive skin and subcutaneous tissue, including lipectomy, of the submental fat pad or double chin. It is important to ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 15838, the physician must document the following information:

• Patient’s diagnosis and the medical necessity for the procedure
• Description of the procedure performed, including the incision technique, lipectomy, and excision of excessive skin
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the performing physician

7. Billing guidelines

When billing for CPT 15838, it is important to follow the appropriate guidelines. Ensure that the procedure meets the specific criteria outlined in the code description. Additionally, consider any additional services or procedures performed during the same encounter and follow the appropriate bundling and modifier guidelines.

8. Historical information

CPT 15838 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 15838

There are several similar codes to CPT 15838 that describe excision or removal procedures on different parts of the body. Some examples include:

• CPT 15830: Excision, excessive skin and subcutaneous tissue (includes lipectomy); arms
• CPT 15832: Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen
• CPT 15834: Excision, excessive skin and subcutaneous tissue (includes lipectomy); back and/or flank
• CPT 15836: Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
• CPT 15839: Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area

9. Examples

1. A patient undergoes CPT 15838 to remove excess skin and subcutaneous tissue of the submental fat pad, resulting in a more defined jawline.
2. A physician performs CPT 15838 on a patient with a double chin, improving the overall contour and appearance of the neck.
3. Aesthetic surgery center offers CPT 15838 as part of their services to address submental fat and provide patients with a more youthful and defined neck and jawline.
4. A plastic surgeon performs CPT 15838 on a patient who desires a more sculpted and contoured neck and chin area.
5. A patient undergoes CPT 15838 to remove excess skin and subcutaneous tissue after significant weight loss, achieving a more proportionate and aesthetically pleasing neck and jawline.
6. A cosmetic surgeon performs CPT 15838 on a patient who is unhappy with the appearance of their double chin, resulting in a more defined and youthful profile.
7. A patient undergoes CPT 15838 to address the submental fat pad, improving their self-confidence and overall satisfaction with their appearance.
8. A plastic surgeon performs CPT 15838 on a patient who desires a more defined and sculpted jawline, enhancing their facial aesthetics.
9. Aesthetic clinic offers CPT 15838 as a solution for patients seeking to improve the appearance of their neck and chin area.
10. A patient undergoes CPT 15838 to remove excess skin and subcutaneous tissue, achieving a more youthful and rejuvenated appearance.