Wiki Panniculectomy (15830 - 15847)

[lapcpc]

Has anyone had any difficulty billing Medicare for a panniculectomy (15830 - 15847)? I have tried to look for an LCD for our local Medicare carrier (New Hampshire is where we are located), but I could not find anything.

Any help would be greatly appreciated.

Thanks, Lori

 

[thegranddiva1]

Hi I am in Florida and MCare considers this cosmetic surgery, you have to appeal the denial with especially detailed medical records and op report. They still may deny but it's the only thing that you can do. If they deny the claim, but state that if additional records are available you can appeal to the next level, do it you never know.

Good luck,

Roni Jones, CPC

 

[sbicknell]

This is a medical term for tummy tuck. Most policies consider this a cosmetic surgery. Your DX and documentation must support the medical necessity for this surgery. I have posted one payer's payment guidelines just to show kind of what they are looking for in the documentation.

If the documentation does support medical necessity, you will have to resubmit with the op report and most likely the office note (decision for surgery) in order to get it past the "cosmetic denial" and get it reviewed at a higher level.

Only one panniculectomy is covered, per member, in a lifetime. Therefore, it is extremely important that weight loss goals have been met and that weight has stabilized.

The following criteria must be met:
1. The lower extent of the pannus is below the symphysis pubis, as demonstrated by photographs; and
2. There is clinical documentation of recurrent and unrelenting skin
condition (such as intertriginous dermatitis, panniculitis, cellulitis, or
skin ulcerations) that is unresponsive to at least three months of
medical treatment.

OR

3. Following bariatric surgery or adherence to a nonsurgical program of
weight maintenance (i.e., diet, exercise and possible medication):
a. The lower extent of the pannus is below the symphysis pubis, as
demonstrated by photographs; and
b. There is clinical documentation of a BMI loss ≥ 10 and the
member’s BMI must be ≤ 35; and
c. A stable weight loss, plus or minus 10 pounds, has been
maintained for six months; and
d. For members who have had bariatric surgery -- member must be
at least 18 months post surgery.

 

[lapcpc]

Thank you all for your help.

Lori