Description
Documentation will be reviewed to determine if CPT code 15734 warranted separate reimbursement given that a flap is considered inclusive to breast reconstruction (19357-19364, 19367-19369) or breast prosthesis (19340, 19342). Documentation will be reviewed to support a that the flap (15734) was performed at a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same individual.
Affected Code(s)
15734
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. 42 CFR §424.5(a)(6)- Basic conditions- Sufficient information
9. NCCI, Chapter 1- General Correct Coding Policies
10. NCCI, Chapter 3- Surgery: Integumentary System; CPT codes 10000-19999; J. Breast (Incision, Excision, Introduction, Repair and Reconstruction), #7
11. AMA CPT Codebook
12. CPT Assistant, July 2021, Volume 31, Issue 7, Page 8-Surgery-Integumentary System, 15734
13. CPT Assistant, April 2014, Volume 24, Issue 4, Page 10- Surgery: Integumentary System, Repair Abdominal Wall After Free Flap for Breast Reconstruction, 15734
14. CPT Assistant, December 2012, Volume 22, Issue 12, page 6- Island Pedicle Flaps