Understanding ICD9-CM and Procedure Codes to Know What is Covered?

My insurance approved a surgery for me using ICD9-CM Code 728.84 (Diastasis of Muscle). There is a Procedure Code of 15847 with a description of: EXC SKIN ABD ADD-ON. What does this mean? I was told by my primary care physician that he believed my Diastasis recti AND abdominoplasty was going to be covered by insurance. The specialist doing the surgery said only the repair of the Diastasis was going to be covered. Based on the aforementioned coding, what do you think will be covered?

Doctor Answers 3

Insurance coverage

If you are trying to obtain  insurance coverage for anything having to do with a tummy tuck or a repair of a rectus diastasis, you will likely have a difficult time succeeding.  Insurance carriers almost never cover the cost for a repair of a rectus diastasis, that is, the muscle tightening procedure.  They will occasionally cover the cost or the skin removal, or a panniculectomy, if you have lost a large amount of weight or the hanging skin is repeatedly getting infected or irritated, but it is unlikely.  Your primary care doctor, while I'm sure means well and can see the benefit of the surgery, does not necessarily know whether insurance will cover the procedure.  Primary care doctors simply do not see this problem often and are not often familiar with how insurance companies deal with this issue.  The only way to know prior to surgery is to have the plastic surgeon try  to obtain per-authorization from the insurance company, but, again, it is not likely.  Good luck!

Insurance coverage

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If you are trying to obtain  insurance coverage for anything having to do with a tummy tuck or a repair of a rectus diastasis, you will likely have a difficult time succeeding.  Insurance carriers almost never cover the cost for a repair of a rectus diastasis, that is, the muscle tightening procedure.  They will occasionally cover the cost or the skin removal, or a panniculectomy, if you have lost a large amount of weight or the hanging skin is repeatedly getting infected or irritated, but it is unlikely.  Your primary care doctor, while I'm sure means well and can see the benefit of the surgery, does not necessarily know whether insurance will cover the procedure.  Primary care doctors simply do not see this problem often and are not often familiar with how insurance companies deal with this issue.  The only way to know prior to surgery is to have the plastic surgeon try  to obtain per-authorization from the insurance company, but, again, it is not likely.  Good luck!

Coding

In my state, none of this is covered by insurance including the diastasis repair.  Even if the insurance company states that they will cover it in a predetermination letter, this is not a guarantee of payment and most end up denying it after surgery.

Coding

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In my state, none of this is covered by insurance including the diastasis repair.  Even if the insurance company states that they will cover it in a predetermination letter, this is not a guarantee of payment and most end up denying it after surgery.

Coding Confusion

Coding for abdominal procedures can be very confusing.  A full abdominoplasty includes 15830 (removal of skin below the belly button only - without repositioning of the belly button or tightening of the rectus muscle), AND 15847 (removal of skin, repostioning of the belly button, and tightening of the muscle)...but 15847 is an "Add-On" code that is only used with the 15830 code.  In this setting, my interpretation would be consistent with your surgeon's, in that only the muscle repair would be covered and there would be an additional charge for removing excess skin.  Other plastic surgeons may view this differently.  Also, while most abdominoplasty paitents can also benefit from abdominal liposuction (15877), this is never covered by insurance.  lhc

Lee H. Colony, MD, FACS
Lansing Plastic Surgeon
5.0 out of 5 stars 26 reviews

Coding Confusion

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Coding for abdominal procedures can be very confusing.  A full abdominoplasty includes 15830 (removal of skin below the belly button only - without repositioning of the belly button or tightening of the rectus muscle), AND 15847 (removal of skin, repostioning of the belly button, and tightening of the muscle)...but 15847 is an "Add-On" code that is only used with the 15830 code.  In this setting, my interpretation would be consistent with your surgeon's, in that only the muscle repair would be covered and there would be an additional charge for removing excess skin.  Other plastic surgeons may view this differently.  Also, while most abdominoplasty paitents can also benefit from abdominal liposuction (15877), this is never covered by insurance.  lhc

Lee H. Colony, MD, FACS
Lansing Plastic Surgeon

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.