Coding Ahead
CasePilot
Medical Coding Assistant
Case2Code
Search and Code Lookup Tool
RedactPHI
HIPAA-Compliant PHI Redaction
DetectICD10CM
ICD-10-CM Code Detection
Log in Register free account
1 code page views remaining. Guest accounts are limited to 1 page view. Register free account to get 5 more views.
Log in Register free account

Official Description

Rhytidectomy; cheek, chin, and neck

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 15828 refers to a rhytidectomy, specifically targeting the areas of the cheek, chin, and neck. In simpler terms, this surgical intervention is commonly known as a facelift, which aims to reduce the appearance of sagging skin and wrinkles in these facial regions. The physician performs the procedure by making an incision along a natural wrinkle line, which helps to conceal the surgical scar. During the operation, excess skin is carefully trimmed away to achieve a smoother and more youthful contour. After the removal of the excess skin, the wound is meticulously closed in multiple layers to promote optimal healing and minimize scarring. This technique not only enhances the aesthetic appearance of the face but also restores a more youthful profile by tightening the underlying tissues.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The rhytidectomy procedure indicated by CPT® Code 15828 is performed for various reasons related to the aging process and cosmetic enhancement. The following conditions or symptoms may warrant this surgical intervention:

  • Excess Skin The presence of sagging or loose skin in the cheek, chin, and neck areas that contributes to an aged appearance.
  • Wrinkles The development of deep wrinkles or folds in the skin that are resistant to non-surgical treatments.
  • Loss of Facial Contour A noticeable decrease in the definition of facial features, leading to a less youthful appearance.

2. Procedure

The rhytidectomy procedure involves several critical steps to ensure effective results. Each step is designed to address the specific areas of concern while maintaining the integrity of the surrounding tissues.

  • Step 1: Incision Creation The surgeon begins by making an incision in a naturally occurring wrinkle of the cheek, chin, or neck. This strategic placement helps to conceal the scar post-surgery.
  • Step 2: Skin Trimming Once the incision is made, the surgeon carefully trims away excess skin. This step is crucial for removing sagging skin and improving the overall contour of the face.
  • Step 3: Wound Closure After the excess skin has been removed, the surgeon closes the wound in multiple layers. This layered closure technique is essential for promoting proper healing and minimizing the risk of complications.

3. Post-Procedure

Following the rhytidectomy, patients can expect a recovery period that may involve swelling, bruising, and discomfort in the treated areas. Post-procedure care typically includes following the surgeon's instructions regarding wound care, activity restrictions, and follow-up appointments. Patients are advised to avoid strenuous activities and to keep the head elevated to reduce swelling. The healing process may take several weeks, during which the final results of the procedure will gradually become more apparent as swelling subsides and the skin settles into its new position.

Short Descr RHYTIDECTOMY CHEEK CHN & NCK
Medium Descr RHYTIDECTOMY CHEEK CHIN & NECK
Long Descr Rhytidectomy; cheek, chin, and neck
Status Code Restricted Coverage
Global Days 000 - Endoscopic or Minor Procedure
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 1 - 150% payment adjustment for bilateral procedures applies.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Procedure or Service, Multiple Reduction Applies
ASC Payment Indicator Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P6A - Minor procedures - skin
MUE 1
CCS Clinical Classification 175 - Other OR therapeutic procedures on skin and breast
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
50 Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
GC This service has been performed in part by a resident under the direction of a teaching physician
GZ Item or service expected to be denied as not reasonable and necessary
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
Date
Action
Notes
2025-01-01 Changed Short Description changed.
2013-01-01 Changed Medium Descriptor changed.
Pre-1990 Added Code added.
Code
Description
Code
Description
Code
Description
Code
Description
Code
Description
CasePilot

Get instant expert-level medical coding assistance.

Ask about:
CPT Codes Guidelines Modifiers Crosswalks NCCI Edits Compliance Medicare Coverage
Example: "What is CPT code 99213?" or "Guidelines for E/M services"