Learn exclusions to Medicare’s cosmetic surgery rules.
Patients who undergo significant weight loss, either through diet and exercise changes or due to a surgical procedure, can have loose skin that causes discomfort and the inability to go about daily activities. As a surgical coder, are you familiar with the payer rules and coding guidelines you need to follow when a physician performs the surgery to remove excess skin?
Read on to familiarize yourself with the procedure and diagnosis codes, and what documentation is required for panniculectomy procedures.
Understand the Panniculectomy Procedure
Panniculectomy is a surgical procedure where the surgeon excises extra skin and subcutaneous tissue from the patient’s abdomen but doesn’t elevate the flap or perform muscle plication. Abdominal pannus is excess skin and fat that hangs from the lower abdomen. A plastic surgeon may place a grade on the pannus using a scale from 1 to 5 — as the patient’s weight increases, the grade increases.
Following significant weight loss, the patient may have excessive skin in the lower abdominal area, which the plastic surgeon can excise through a panniculectomy procedure. Depending on the amount of skin and fat removed, the surgeon may also perform fascial plication and reposition the umbilicus. This procedure is known as an abdominoplasty.
In the CPT® code set, you’ll find the following codes for panniculectomy and abdominoplasty procedures:
The abdominoplasty procedure code, +15847, is an add-on code and must be reported with a primary procedure code.
Examine Other Excision of Excessive Skin Codes
Patients may also have extra skin and fat tissue in other areas of their body following weight loss. Plastic surgeons can remove this excess tissue as well. You’ll report any of the following codes for tissue removal from areas of the body other than the abdomen:
Make sure to pay attention to the end of the descriptor to find the correct code for the body structure that was operated on.
Separate Reconstructive From Cosmetic Surgery
Medicare will cover panniculectomy when it is performed as a reconstructive surgery. The procedure is deemed a reconstructive surgery when the surgeon performs the operation to alleviate complaints of chronic pain, ulcers due to skin folds, and the inability to walk normally.
When these conditions or symptoms are properly documented, Medicare may cover the procedure. However, if the panniculectomy is performed as a cosmetic surgery, Medicare will not cover the procedure — but there are exceptions. According to chapter 16 of the Medicare Benefit Policy Manual, “Cosmetic surgery includes any surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member.”
In other words, if the surgery takes place for therapeutic purposes, such as following weight-loss surgery, but also serves a cosmetic purpose, then the reconstructive surgery won’t be considered cosmetic.
Documentation requirements: The Centers for Medicare & Medicaid Services (CMS) requires physicians to document specific information in the medical record for panniculectomy and abdominoplasty procedures.
According to Medicare Billing and Coding article >A58573, the medical record must contain the following:
Medicare also recommends including pictures of the pannus and underlying skin before the surgery is performed.
Don’t Forget the Diagnosis Codes
As with any medical procedure performed, the physician must show medical necessity for the procedure when requesting reimbursement. Excision of excess skin and subcutaneous tissue is no different, and you’ll need to assign the correct ICD-10-CM code on the claim.
Assign L98.7 (Excessive and redundant skin and subcutaneous tissue) when the patient presents for surgery to remove the extra skin and tissue. This code features several additional conditions under the main descriptor, including “[l]oose or sagging skin following bariatric surgery weight loss” and “[l]oose or sagging skin following dietary weight loss.”
When the surgeon performs a panniculectomy, you’ll assign M79.3 (Panniculitis, unspecified) to report the patient’s condition for the procedure.
According to the Medicare Billing and Coding article mentioned above, you may report L98.7 or M79.3 as the primary diagnosis code. You’ll use these codes “with ICD-10-CM codes L30.4 [Erythema intertrigo], R26.2 [Difficulty in walking, not elsewhere classified], or Z74.09 [Other reduced mobility] reported as the secondary diagnosis.”
Mike Shaughnessy, BA, CPC, Development Editor, AAPC
