LCD Reference Article Billing and Coding Article

Billing and Coding: Cosmetic and Reconstructive Surgery

A58573

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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General Information

Source Article ID
N/A
Article ID
A58573
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Cosmetic and Reconstructive Surgery
Article Type
Billing and Coding
Original Effective Date
07/11/2021
Revision Effective Date
10/01/2024
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L38914, Cosmetic and Reconstructive Surgery. Please refer to the LCD for reasonable and necessary requirements.


Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Documentation Requirements

For all procedures:

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.


Documentation Requirements for Specified Services

Dermabrasion

  1. The medical record must describe the beneficiary’s disease process of the rhinophyma that is being treated with dermabrasion.

Abdominal Lipectomy/Panniculectomy

  1. The medical record must contain the following information:
    • Description of the pannus and underlying skin.
    • Documentation that the panniculus causes chronic intertrigo (dermatitis occurring on the opposed surfaces of the skin, skin irritation, infection, or chafing).
    • Description of functional impairments (e.g., difficulty walking, exercising, or impairment in activities of daily living).
    • Description of conservative treatment the beneficiary has received and the results of treatment.
    • Preoperative photographs of the pannus and underlying skin are recommended.

Reconstructive Breast Surgery: Removal of Breast Implants

  1. The medical record must describe the condition which supports the removal of the breast implant(s) as medically reasonable and necessary.

Reduction Mammaplasty

  1. The beneficiary's medical record must contain the following information:
    • Height and weight.
    • Clinical evaluation of the signs or symptoms ascribed to the macromastia, therapies prior to reduction mammaplasty and the responses to these therapies.
    • Mammogram report for age appropriate population.
    • The operative report with documentation of the weight of tissue removed from each breast, obtained in the operating room.
    • The pathology report of the tissue removed from each breast.

Mastectomy for gynecomastia

  1. Glandular breast tissue confirming true gynecomastia is documented on physical exam and/or mammography.
  2. Documentation that the gynecomastia persists, despite correction of any underlying causes.
  3. Documentation supporting that the gynecomastia is classified as Grade III or IV per the American Society of Plastic Surgeons (ASPS) classification when the procedure is performed in males.
  4. Documentation that hormonal causes, including hyperthyroidism, estrogen excess, hyperprolactinemia and hypogonadism have been excluded by appropriate laboratory testing (e.g., with levels of thyroid stimulating hormone [TSH], estradiol, prolactin, testosterone and/or luteinizing hormone [LH])
  5. Documentation supporting that gynecomastia persists after 3 to 4 months of unsuccessful medical treatment, the use of potential gynecomastia-inducing drugs and substances has been ruled out and gynecomastia persists for at least one year.

Rhinoplasty

  1. Photographic documentation of the patient’s condition is recommended to help support medical necessity if documentation is requested.
  2. The medical record must include a description of the condition requiring the rhinoplasty.
  3. When rhinoplasty is being performed for chronic obstruction, the medical record must indicate what is causing the obstruction.

Septoplasty

  1. The medical record must describe the conservative medical management utilized and the length of time that the treatment was trialed for septal deviation causing nasal airway obstruction.
  2. The medical record must contain the medical and antibiotic therapy that was utilized, and the length of the time treatment was trialed for recurrent sinusitis secondary to deviated septum.
  3. The medical record must contain the medical management utilized and the length of time that the treatment was trialed for obstructed nasal breathing due to septal deformity or deviation that is interfering with the effective use of Continuous Positive Airway Pressure (CPAP) for the treatment of an obstructive sleep disorder.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description

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N/A

Revenue Codes

Code Description

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N/A

CPT/HCPCS Codes

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N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM code supports medical necessity and provides coverage for CPT/HCPCS code: 15781 for Dermabrasion.

Group 1 Codes
Code Description
L71.1 Rhinophyma

Group 2

(5 Codes)
Group 2 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT/HCPCS codes: 15830, 15847, and 15877 for Abdominal Lipectomy/ Panniculectomy.

Group 2 Codes
Code Description
L30.4* Erythema intertrigo
L98.7* Excessive and redundant skin and subcutaneous tissue
M79.3* Panniculitis, unspecified
R26.2* Difficulty in walking, not elsewhere classified
Z74.09* Other reduced mobility
Group 2 Medical Necessity ICD-10-CM Codes Asterisk Explanation

Note: Dual diagnosis reporting is required to support the service as medically reasonable and necessary. ICD-10-CM diagnosis codes L98.7 or M79.3 should be reported as the primary diagnosis with ICD-10-CM codes L30.4, R26.2, or Z74.09 reported as the secondary diagnosis.

Group 3

(58 Codes)
Group 3 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT/HCPCS codes: 19316, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, and 19396 for Reconstructive Breast Surgery: Removal of Breast Implants.

Group 3 Codes
Code Description
C50.011 Malignant neoplasm of nipple and areola, right female breast
C50.012 Malignant neoplasm of nipple and areola, left female breast
C50.021 Malignant neoplasm of nipple and areola, right male breast
C50.022 Malignant neoplasm of nipple and areola, left male breast
C50.111 Malignant neoplasm of central portion of right female breast
C50.112 Malignant neoplasm of central portion of left female breast
C50.121 Malignant neoplasm of central portion of right male breast
C50.122 Malignant neoplasm of central portion of left male breast
C50.211 Malignant neoplasm of upper-inner quadrant of right female breast
C50.212 Malignant neoplasm of upper-inner quadrant of left female breast
C50.221 Malignant neoplasm of upper-inner quadrant of right male breast
C50.222 Malignant neoplasm of upper-inner quadrant of left male breast
C50.311 Malignant neoplasm of lower-inner quadrant of right female breast
C50.312 Malignant neoplasm of lower-inner quadrant of left female breast
C50.321 Malignant neoplasm of lower-inner quadrant of right male breast
C50.322 Malignant neoplasm of lower-inner quadrant of left male breast
C50.411 Malignant neoplasm of upper-outer quadrant of right female breast
C50.412 Malignant neoplasm of upper-outer quadrant of left female breast
C50.421 Malignant neoplasm of upper-outer quadrant of right male breast
C50.422 Malignant neoplasm of upper-outer quadrant of left male breast
C50.511 Malignant neoplasm of lower-outer quadrant of right female breast
C50.512 Malignant neoplasm of lower-outer quadrant of left female breast
C50.521 Malignant neoplasm of lower-outer quadrant of right male breast
C50.522 Malignant neoplasm of lower-outer quadrant of left male breast
C50.611 Malignant neoplasm of axillary tail of right female breast
C50.612 Malignant neoplasm of axillary tail of left female breast
C50.621 Malignant neoplasm of axillary tail of right male breast
C50.622 Malignant neoplasm of axillary tail of left male breast
C50.811 Malignant neoplasm of overlapping sites of right female breast
C50.812 Malignant neoplasm of overlapping sites of left female breast
C50.821 Malignant neoplasm of overlapping sites of right male breast
C50.822 Malignant neoplasm of overlapping sites of left male breast
C79.2 Secondary malignant neoplasm of skin
C79.81 Secondary malignant neoplasm of breast
D05.01 Lobular carcinoma in situ of right breast
D05.02 Lobular carcinoma in situ of left breast
D05.11 Intraductal carcinoma in situ of right breast
D05.12 Intraductal carcinoma in situ of left breast
D05.81 Other specified type of carcinoma in situ of right breast
D05.82 Other specified type of carcinoma in situ of left breast
D24.1 Benign neoplasm of right breast
D24.2 Benign neoplasm of left breast
D48.61 Neoplasm of uncertain behavior of right breast
D48.62 Neoplasm of uncertain behavior of left breast
N65.0 Deformity of reconstructed breast
N65.1 Disproportion of reconstructed breast
T85.41XA Breakdown (mechanical) of breast prosthesis and implant, initial encounter
T85.42XA Displacement of breast prosthesis and implant, initial encounter
T85.43XA Leakage of breast prosthesis and implant, initial encounter
T85.44XA Capsular contracture of breast implant, initial encounter
T85.49XA Other mechanical complication of breast prosthesis and implant, initial encounter
T85.79XA Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter
Z42.1 Encounter for breast reconstruction following mastectomy
Z45.811 Encounter for adjustment or removal of right breast implant
Z45.812 Encounter for adjustment or removal of left breast implant
Z48.3 Aftercare following surgery for neoplasm
Z85.3 Personal history of malignant neoplasm of breast
Z98.82 Breast implant status

Group 4

(22 Codes)
Group 4 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT/HCPCS code: 19318 for reduction mammaplasty and gigantomastia of pregnancy.

Group 4 Codes
Code Description
L26* Exfoliative dermatitis
L30.4* Erythema intertrigo
L53.8* Other specified erythematous conditions
L54* Erythema in diseases classified elsewhere
M25.511* Pain in right shoulder
M25.512* Pain in left shoulder
M53.1* Cervicobrachial syndrome
M54.2* Cervicalgia
M54.6* Pain in thoracic spine
M54.89* Other dorsalgia
N62 Hypertrophy of breast
N64.1* Fat necrosis of breast
N64.4* Mastodynia
N64.81* Ptosis of breast
N65.1 Disproportion of reconstructed breast
O91.211* Nonpurulent mastitis associated with pregnancy, first trimester
O91.212* Nonpurulent mastitis associated with pregnancy, second trimester
O91.213* Nonpurulent mastitis associated with pregnancy, third trimester
R21* Rash and other nonspecific skin eruption
Z42.1* Encounter for breast reconstruction following mastectomy
Z42.8* Encounter for other plastic and reconstructive surgery following medical procedure or healed injury
Z85.3* Personal history of malignant neoplasm of breast
Group 4 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Note: The primary diagnosis code N62 must be billed with one of the diagnosis codes listed in Group 4 Codes as a secondary code for reduction mammaplasty.

**Note: N65.1 may be used as a standalone code when billing for surgery on the unaffected breast to restore symmetry following breast cancer surgery on the contralateral breast.

Group 5

(1 Code)
Group 5 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM code supports medical necessity and provides coverage for CPT/HCPCS code: 19300 for Mastectomy for Gynecomastia.

Group 5 Codes
Code Description
N62 Hypertrophy of breast

Group 6

(50 Codes)
Group 6 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT/HCPCS codes: 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30468 and 30520 for Rhinoplasty/Reconstructive Nasal Surgery.

Group 6 Codes
Code Description
C30.0 Malignant neoplasm of nasal cavity
C41.0 Malignant neoplasm of bones of skull and face
C43.31 Malignant melanoma of nose
C43.39 Malignant melanoma of other parts of face
C44.311 Basal cell carcinoma of skin of nose
C44.319 Basal cell carcinoma of skin of other parts of face
C44.321 Squamous cell carcinoma of skin of nose
C44.329 Squamous cell carcinoma of skin of other parts of face
C44.391 Other specified malignant neoplasm of skin of nose
C44.399 Other specified malignant neoplasm of skin of other parts of face
C76.0 Malignant neoplasm of head, face and neck
D03.39 Melanoma in situ of other parts of face
D04.39 Carcinoma in situ of skin of other parts of face
D14.0 Benign neoplasm of middle ear, nasal cavity and accessory sinuses
D16.4 Benign neoplasm of bones of skull and face
D22.39 Melanocytic nevi of other parts of face
D23.39 Other benign neoplasm of skin of other parts of face
J32.0 Chronic maxillary sinusitis
J32.1 Chronic frontal sinusitis
J32.2 Chronic ethmoidal sinusitis
J32.3 Chronic sphenoidal sinusitis
J32.4 Chronic pansinusitis
J34.0 Abscess, furuncle and carbuncle of nose
J34.1 Cyst and mucocele of nose and nasal sinus
J34.2 Deviated nasal septum
J34.8201 Internal nasal valve collapse, static
J34.8202 Internal nasal valve collapse, dynamic
J34.8211 External nasal valve collapse, static
J34.8212 External nasal valve collapse, dynamic
J34.89 Other specified disorders of nose and nasal sinuses
Q30.0 Choanal atresia
Q30.8 Other congenital malformations of nose
Q35.1 Cleft hard palate
Q35.3 Cleft soft palate
Q35.5 Cleft hard palate with cleft soft palate
Q35.7 Cleft uvula
Q36.0 Cleft lip, bilateral
Q36.1 Cleft lip, median
Q36.9 Cleft lip, unilateral
Q37.0 Cleft hard palate with bilateral cleft lip
Q37.1 Cleft hard palate with unilateral cleft lip
Q37.2 Cleft soft palate with bilateral cleft lip
Q37.3 Cleft soft palate with unilateral cleft lip
Q37.4 Cleft hard and soft palate with bilateral cleft lip
Q37.5 Cleft hard and soft palate with unilateral cleft lip
Q67.0 Congenital facial asymmetry
Q67.1 Congenital compression facies
Q67.4 Other congenital deformities of skull, face and jaw
S02.2XXA Fracture of nasal bones, initial encounter for closed fracture
S02.2XXB Fracture of nasal bones, initial encounter for open fracture
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
Z41.1 Encounter for cosmetic surgery
N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description

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N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/01/2024 R1

Article revised and published on 10/24/2024 effective for dates of service on and after 10/01/2024 to reflect the annual ICD-10-CM Code Updates. The following ICD-10-CM codes have been added to Group 6 in ICD-10-CM Codes that Support Medical Necessity: J34.8201, J34.8202, J34.8211, and J34.8212. Minor formatting changes were made throughout the article.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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