Cosmetic and Reconstructive Surgery (L30733)
Contractor Information
|
Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type Carrier - FI - MAC |
LCD Information
Document Information
L30733 LCD Title Cosmetic and Reconstructive Surgery Contractor's Determination Number GSURG-032 AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date For services performed on or after 11/15/2010 Original Determination Ending Date Revision Effective Date For services performed on or after 10/01/2011 Revision Ending Date |
CMS National Coverage Policy
CMS PUB. 100-3 Medicare National Coverage Determinations Manual
§140.2 - Breast Reconstruction Following Mastectomy
§140.4 - Plastic Surgery to Correct "Moon Face"
§250.5 - Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS)
CMS PUB. 100-02 Medicare Benefit Policy Manual
180 - Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare.
CMS PUB 100-04 Medicare Claims Processing Manual
260 - Dermal Injections for Treatment of Facial Lipodystrophy Syndrome (LDS)
Change Request (CR) 6953, CR 6996
1862 (a)(1)(A) Medically Reasonable & Necessary.
1862 (a)(1)(D) Investigational or Experimental.
§140.2 - Breast Reconstruction Following Mastectomy
§140.4 - Plastic Surgery to Correct "Moon Face"
§250.5 - Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS)
CMS PUB. 100-02 Medicare Benefit Policy Manual
180 - Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare.
CMS PUB 100-04 Medicare Claims Processing Manual
260 - Dermal Injections for Treatment of Facial Lipodystrophy Syndrome (LDS)
Change Request (CR) 6953, CR 6996
1862 (a)(1)(A) Medically Reasonable & Necessary.
1862 (a)(1)(D) Investigational or Experimental.
Indications and Limitations of Coverage and/or Medical Necessity
A.
According to the American Society of Plastic and Reconstructive
Surgeons, the specialty of plastic surgery includes reconstructive and
cosmetic procedures:
1. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.
2. Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.
B. Indications for specific surgical procedures:
1. Breast reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is covered (19316, 19318, 19324, 19325, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396)
The applicable ICD-9 codes include: V10.3, V51.0, 173.50, 173.51, 173.52, 173.59, 174.0-174.9, 175.0-175.9, 198.2, 198.81, 217, 232.5, 233.0, 610.0-610.9
2. Removal or revision of a breast implant (CPT 19328, 19330, 19370, 19371, 19380) is considered medically necessary when it is removed for one of the following reasons:
a. Mechanical complication of breast prosthesis; including rupture or failed implant, implant extrusion (996.54).
b. Infection or inflammatory reaction due to a breast prosthesis; including infected breast implant, or rejection of breast implants (996.69).
c. Other complication of internal breast implant; including siliconoma, granuloma, interference with diagnosis of breast cancer, painful capsular contracture with disfigurement (996.79)
3. Reduction Mammoplasty (CPT 19318) is the surgical reshaping of the breasts to reduce or lift enlarged or sagging breasts. Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit.
Macromastia (breast hypertrophy) is an increase in the volume and weight of breast tissue relative to the general body habitus. Breast hypertrophy may adversely affect other body systems: musculoskeletal, respiratory, and integumentary. Unilateral hypertrophy may result in symptoms following contralateral mastectomy.
Medical necessity for a reduction mammoplasty is limited to circumstances in which:
- There are signs and/or symptoms resulting from the enlarged breasts (macromastia) that have not responded adequately to non-surgical interventions, and
- To reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery.
Non-surgical interventions preceding reduction mammoplasty should include as appropriate, but are not limited to, the following:
- Determining the macromastia is not due to an active endocrine or metabolic process
- Determining the symptoms are refractory to appropriately fitted supporting garments, or following unilateral mastectomy, persistent with an appropriately fitted prosthesis or reconstruction therapy at the site of the absent breast.
- Determining that dermatologic signs and/or symptoms are refractory to, or recurrent following, a completed course of medical management.
A medically reasonable and necessary reduction mammoplasty could be indicated in the presence of significantly enlarged breasts and the presence of at least one of the following signs and/or symptoms:
A. Back or neck or shoulder pain (719.41, 723.1, 724.1, 724.5) from macromastia (611.1) and unrelieved by 6 months of:
1. Conservative analgesia,
2. Supportive measures (garment, etc.),
3. Physical Therapy, or
B Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity. (715.28)
C. Intertriginous maceration or infection of the inframammary skin refractory to dermatologic measures. (695.89)
D. Permanent shoulder grooving with skin irritation by supporting garment (bra strap) (709.9)
.
The amount of breast tissue to be removed must be proportional to the body surface area (BSA) per the Schnur scale below. If only one breast meets the Schnur scale criteria; breast tissue may be removed from the other breast in order to achieve symmetry.
Schnur Scale:
Body Surface
Area (m2) Average grams of tissue per breast to be removed
1.40-1.50 218-260
1.51-1.60 261-310
1.61-1.70 311-370
1.71-1.80 371-441
1.81-1.90 442-527
1.91-2.00 528-628
2.01-2.10 629-750
2.11-2.20 751-895
2.21-2.30 896-1068
2.31-2.40 1069-1275
2.41-2.50 1276-1522
2.51-2.60 1523-1806
2.61-2.70 1807-2154
2.71-2.80 2155-2568
2.81-2.90 2569-3061
2.91-3.00 3062-3650
4. Mastectomy for gynecomastia (19300)
Gynecomastia is the excessive growth of the male mammary glands (611.1). These conditions can cause significant clinical manifestations when the excessive breast weight adversely affects the supporting structures of the shoulders, neck, and trunk. Payment may be made for this procedure if it is documented that the tissue is primarily breast tissue and not just adipose (fatty tissue).
5. Tattooing to correct color defects of the skin (11920, 11921, 11922) may be considered reconstructive (V51.0, V51.8) when performed in connection with a payable post-mastectomy reconstruction, or for reconstruction following trauma or removal of cancer from an eyelid, eyebrow or lip(s).
6. Punch graft hair transplant (CPT 15775-15776) may be considered reconstructive when it is performed for eyebrow(s) replacement following a burn injury or tumor removal (ICD-9 codes 173.30, 173.31, 173.32, 173.39, 216.3, 232.3, 232.8, 238.2, 959.01, 941.27, 941.37).
7. Rhinoplasty (CPT codes 30400-30450) that is performed to improve nasal respiratory function due to airway obstruction or stricture, repair deficits caused by trauma, revise structural deformities produced by trauma or nasal cutaneous disease, or replace nasal tissue lost after tumor ablative surgery is covered.
a. Nasal fracture (802.0, 802.1)
b. Benign or malignant neoplasms (160.0, 170.0, 172.3, 173.30, 173.31, 173.32, 173.39, 195.0, 212.0, 213.0, 216.3, 232.3)
c. Nasal Obstruction (478.19)
8. Chemical Peel (15788-15793)
Is covered for the treatment of Actinic Keratosis (702.0).
9. Dermabrasion, segmental, face (15781)
Is covered for the treatment of rhinophyma (695.3).
10. Dermal injections for facial LDS using dermal fillers approved by the FDA for this purpose, and then only in HIV-infected Medicare beneficiaries who manifest depression secondary to the physical stigma of HIV treatment will be covered. Effective for claims with dates of service on and after March 23, 2010,
See Pub. 100-03, NCD, chapter 1, section 250.5, for specific coverage criteria. See Pub. 100-04, Claims Processing Manual, chapter 32, section 260, for specific claims payment/coding instructions.
C. The following procedures will be considered on an individual basis.
1. Rhytidectomy, (15828, 15829) is considered medically necessary to correct a functional impairment as a result of a disease state ie; facial paralysis. Often this procedure is performed in conjunction with other procedures to correct the impairment.
2. Excision, excessive skin and subcutaneous tissue (including lipectomy); abdomen (abdominoplasty) (15830) will only be considered reasonable and medically necessary when these procedures are performed due to another surgery being done at the same time and would effect the healing of the surgical incision.
This procedure may also be considered to be medically necessary for the patient that has had a significant weight-loss following the treatment of morbid obesity and there are medical complications such as candidiasis, intertrigo or tissue necrosis that is unresponsive to oral or topical medication.
These claims will be reviewed by the medical staff and considered on a case by case basis. Medical Records will be requested by the Contractor to determine medical necessity. See Documentation Requirements section of this LCD.
1. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.
2. Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.
B. Indications for specific surgical procedures:
1. Breast reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is covered (19316, 19318, 19324, 19325, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396)
The applicable ICD-9 codes include: V10.3, V51.0, 173.50, 173.51, 173.52, 173.59, 174.0-174.9, 175.0-175.9, 198.2, 198.81, 217, 232.5, 233.0, 610.0-610.9
2. Removal or revision of a breast implant (CPT 19328, 19330, 19370, 19371, 19380) is considered medically necessary when it is removed for one of the following reasons:
a. Mechanical complication of breast prosthesis; including rupture or failed implant, implant extrusion (996.54).
b. Infection or inflammatory reaction due to a breast prosthesis; including infected breast implant, or rejection of breast implants (996.69).
c. Other complication of internal breast implant; including siliconoma, granuloma, interference with diagnosis of breast cancer, painful capsular contracture with disfigurement (996.79)
3. Reduction Mammoplasty (CPT 19318) is the surgical reshaping of the breasts to reduce or lift enlarged or sagging breasts. Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit.
Macromastia (breast hypertrophy) is an increase in the volume and weight of breast tissue relative to the general body habitus. Breast hypertrophy may adversely affect other body systems: musculoskeletal, respiratory, and integumentary. Unilateral hypertrophy may result in symptoms following contralateral mastectomy.
Medical necessity for a reduction mammoplasty is limited to circumstances in which:
- There are signs and/or symptoms resulting from the enlarged breasts (macromastia) that have not responded adequately to non-surgical interventions, and
- To reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery.
Non-surgical interventions preceding reduction mammoplasty should include as appropriate, but are not limited to, the following:
- Determining the macromastia is not due to an active endocrine or metabolic process
- Determining the symptoms are refractory to appropriately fitted supporting garments, or following unilateral mastectomy, persistent with an appropriately fitted prosthesis or reconstruction therapy at the site of the absent breast.
- Determining that dermatologic signs and/or symptoms are refractory to, or recurrent following, a completed course of medical management.
A medically reasonable and necessary reduction mammoplasty could be indicated in the presence of significantly enlarged breasts and the presence of at least one of the following signs and/or symptoms:
A. Back or neck or shoulder pain (719.41, 723.1, 724.1, 724.5) from macromastia (611.1) and unrelieved by 6 months of:
1. Conservative analgesia,
2. Supportive measures (garment, etc.),
3. Physical Therapy, or
B Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity. (715.28)
C. Intertriginous maceration or infection of the inframammary skin refractory to dermatologic measures. (695.89)
D. Permanent shoulder grooving with skin irritation by supporting garment (bra strap) (709.9)
.
The amount of breast tissue to be removed must be proportional to the body surface area (BSA) per the Schnur scale below. If only one breast meets the Schnur scale criteria; breast tissue may be removed from the other breast in order to achieve symmetry.
Schnur Scale:
Body Surface
Area (m2) Average grams of tissue per breast to be removed
1.40-1.50 218-260
1.51-1.60 261-310
1.61-1.70 311-370
1.71-1.80 371-441
1.81-1.90 442-527
1.91-2.00 528-628
2.01-2.10 629-750
2.11-2.20 751-895
2.21-2.30 896-1068
2.31-2.40 1069-1275
2.41-2.50 1276-1522
2.51-2.60 1523-1806
2.61-2.70 1807-2154
2.71-2.80 2155-2568
2.81-2.90 2569-3061
2.91-3.00 3062-3650
4. Mastectomy for gynecomastia (19300)
Gynecomastia is the excessive growth of the male mammary glands (611.1). These conditions can cause significant clinical manifestations when the excessive breast weight adversely affects the supporting structures of the shoulders, neck, and trunk. Payment may be made for this procedure if it is documented that the tissue is primarily breast tissue and not just adipose (fatty tissue).
5. Tattooing to correct color defects of the skin (11920, 11921, 11922) may be considered reconstructive (V51.0, V51.8) when performed in connection with a payable post-mastectomy reconstruction, or for reconstruction following trauma or removal of cancer from an eyelid, eyebrow or lip(s).
6. Punch graft hair transplant (CPT 15775-15776) may be considered reconstructive when it is performed for eyebrow(s) replacement following a burn injury or tumor removal (ICD-9 codes 173.30, 173.31, 173.32, 173.39, 216.3, 232.3, 232.8, 238.2, 959.01, 941.27, 941.37).
7. Rhinoplasty (CPT codes 30400-30450) that is performed to improve nasal respiratory function due to airway obstruction or stricture, repair deficits caused by trauma, revise structural deformities produced by trauma or nasal cutaneous disease, or replace nasal tissue lost after tumor ablative surgery is covered.
a. Nasal fracture (802.0, 802.1)
b. Benign or malignant neoplasms (160.0, 170.0, 172.3, 173.30, 173.31, 173.32, 173.39, 195.0, 212.0, 213.0, 216.3, 232.3)
c. Nasal Obstruction (478.19)
8. Chemical Peel (15788-15793)
Is covered for the treatment of Actinic Keratosis (702.0).
9. Dermabrasion, segmental, face (15781)
Is covered for the treatment of rhinophyma (695.3).
10. Dermal injections for facial LDS using dermal fillers approved by the FDA for this purpose, and then only in HIV-infected Medicare beneficiaries who manifest depression secondary to the physical stigma of HIV treatment will be covered. Effective for claims with dates of service on and after March 23, 2010,
See Pub. 100-03, NCD, chapter 1, section 250.5, for specific coverage criteria. See Pub. 100-04, Claims Processing Manual, chapter 32, section 260, for specific claims payment/coding instructions.
C. The following procedures will be considered on an individual basis.
1. Rhytidectomy, (15828, 15829) is considered medically necessary to correct a functional impairment as a result of a disease state ie; facial paralysis. Often this procedure is performed in conjunction with other procedures to correct the impairment.
2. Excision, excessive skin and subcutaneous tissue (including lipectomy); abdomen (abdominoplasty) (15830) will only be considered reasonable and medically necessary when these procedures are performed due to another surgery being done at the same time and would effect the healing of the surgical incision.
This procedure may also be considered to be medically necessary for the patient that has had a significant weight-loss following the treatment of morbid obesity and there are medical complications such as candidiasis, intertrigo or tissue necrosis that is unresponsive to oral or topical medication.
These claims will be reviewed by the medical staff and considered on a case by case basis. Medical Records will be requested by the Contractor to determine medical necessity. See Documentation Requirements section of this LCD.
Coding Information
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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
Revenue Codes:
CPT/HCPCS 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 policy 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 policy should be assumed to apply equally to all Revenue Codes.
| 11920 | TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.0 SQ CM OR LESS |
| 11921 | TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.1 TO 20.0 SQ CM |
| 11922 | TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; EACH ADDITIONAL 20.0 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) |
| 15775 - 15776 | PUNCH GRAFT FOR HAIR TRANSPLANT; 1 TO 15 PUNCH GRAFTS - PUNCH GRAFT FOR HAIR TRANSPLANT; MORE THAN 15 PUNCH GRAFTS |
| 15776 | PUNCH GRAFT FOR HAIR TRANSPLANT; MORE THAN 15 PUNCH GRAFTS |
| 15781 | DERMABRASION; SEGMENTAL, FACE |
| 15788 - 15793 | CHEMICAL PEEL, FACIAL; EPIDERMAL - CHEMICAL PEEL, NONFACIAL; DERMAL |
| 15789 | CHEMICAL PEEL, FACIAL; DERMAL |
| 15792 | CHEMICAL PEEL, NONFACIAL; EPIDERMAL |
| 15793 | CHEMICAL PEEL, NONFACIAL; DERMAL |
| 15828 | RHYTIDECTOMY; CHEEK, CHIN, AND NECK |
| 15829 | RHYTIDECTOMY; SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM (SMAS) FLAP |
| 15830 | EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY |
| 19300 | MASTECTOMY FOR GYNECOMASTIA |
| 19316 | MASTOPEXY |
| 19318 | REDUCTION MAMMAPLASTY |
| 19324 | MAMMAPLASTY, AUGMENTATION; WITHOUT PROSTHETIC IMPLANT |
| 19325 | MAMMAPLASTY, AUGMENTATION; WITH PROSTHETIC IMPLANT |
| 19328 | REMOVAL OF INTACT MAMMARY IMPLANT |
| 19330 | REMOVAL OF MAMMARY IMPLANT MATERIAL |
| 19340 | IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION |
| 19342 | DELAYED INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION |
| 19350 | NIPPLE/AREOLA RECONSTRUCTION |
| 19355 | CORRECTION OF INVERTED NIPPLES |
| 19357 | BREAST RECONSTRUCTION, IMMEDIATE OR DELAYED, WITH TISSUE EXPANDER, INCLUDING SUBSEQUENT EXPANSION |
| 19361 | BREAST RECONSTRUCTION WITH LATISSIMUS DORSI FLAP, WITHOUT PROSTHETIC IMPLANT |
| 19364 | BREAST RECONSTRUCTION WITH FREE FLAP |
| 19366 | BREAST RECONSTRUCTION WITH OTHER TECHNIQUE |
| 19367 | BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP (TRAM), SINGLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE; |
| 19368 | BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP (TRAM), SINGLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE; WITH MICROVASCULAR ANASTOMOSIS (SUPERCHARGING) |
| 19369 | BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP (TRAM), DOUBLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE |
| 19370 | OPEN PERIPROSTHETIC CAPSULOTOMY, BREAST |
| 19371 | PERIPROSTHETIC CAPSULECTOMY, BREAST |
| 19380 | REVISION OF RECONSTRUCTED BREAST |
| 19396 | PREPARATION OF MOULAGE FOR CUSTOM BREAST IMPLANT |
| 30400 - 30450 | RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES AND/OR ELEVATION OF NASAL TIP - RHINOPLASTY, SECONDARY; MAJOR REVISION (NASAL TIP WORK AND OSTEOTOMIES) |
| 30410 | RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP |
| 30420 | RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR |
| 30430 | RHINOPLASTY, SECONDARY; MINOR REVISION (SMALL AMOUNT OF NASAL TIP WORK) |
| 30435 | RHINOPLASTY, SECONDARY; INTERMEDIATE REVISION (BONY WORK WITH OSTEOTOMIES) |
| 30450 | RHINOPLASTY, SECONDARY; MAJOR REVISION (NASAL TIP WORK AND OSTEOTOMIES) |
| C9800 | DERMAL INJECTION PROCEDURE(S) FOR FACIAL LIPODYSTROPHY SYNDROME (LDS) AND PROVISION OF RADIESSE OR SCULPTRA DERMAL FILLER, INCLUDING ALL ITEMS AND SUPPLIES |
| G0429 | DERMAL FILLER INJECTION(S) FOR THE TREATMENT OF FACIAL LIPODYSTROPHY SYNDROME (LDS) (E.G., AS A RESULT OF HIGHLY ACTIVE ANTIRETROVIRAL THERAPY) |
| Q2026 | INJECTION, RADIESSE, 0.1 ML |
| Q2027 | INJECTION, SCULPTRA, 0.1 ML |
ICD-9 Codes that Support Medical Necessity
Breast Reconstruction (CPT Codes: 19316, 19318, 19324, 19325, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396)
| 173.50 | UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM |
| 173.51 | BASAL CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT SCROTUM |
| 173.52 | SQUAMOUS CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT SCROTUM |
| 173.59 | OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM |
| 174.0 - 174.9 | MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE |
| 175.0 - 175.9 | MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST - MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST |
| 198.2 | SECONDARY MALIGNANT NEOPLASM OF SKIN |
| 198.81 | SECONDARY MALIGNANT NEOPLASM OF BREAST |
| 217 | BENIGN NEOPLASM OF BREAST |
| 232.5 | CARCINOMA IN SITU OF SKIN OF TRUNK EXCEPT SCROTUM |
| 233.0 | CARCINOMA IN SITU OF BREAST |
| 610.0 - 610.9 | SOLITARY CYST OF BREAST - BENIGN MAMMARY DYSPLASIA UNSPECIFIED |
| V10.3 | PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST |
| V51.0 | ENCOUNTER FOR BREAST RECONSTRUCTION FOLLOWING MASTECTOMY |
Primary Diagnosis:
| 611.1 | HYPERTROPHY OF BREAST |
Secondary Diagnoses
| 695.89 | OTHER SPECIFIED ERYTHEMATOUS CONDITIONS |
| 709.9 | UNSPECIFIED DISORDER OF SKIN AND SUBCUTANEOUS TISSUE |
| 715.28 | OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING OTHER SPECIFIED SITES |
| 719.41 | PAIN IN JOINT INVOLVING SHOULDER REGION |
| 723.1 | CERVICALGIA |
| 724.1 | PAIN IN THORACIC SPINE |
| 724.5 | BACKACHE UNSPECIFIED |
| 782.1 | RASH AND OTHER NONSPECIFIC SKIN ERUPTION |
| 996.54 | MECHANICAL COMPLICATION OF BREAST PROSTHESIS |
| 996.69 | INFECTION AND INFLAMMATORY REACTION DUE TO OTHER INTERNAL PROSTHETIC DEVICE IMPLANT AND GRAFT |
| 996.79 | OTHER COMPLICATIONS DUE TO OTHER INTERNAL PROSTHETIC DEVICE IMPLANT AND GRAFT |
| 611.1 | HYPERTROPHY OF BREAST |
| V51.0 | ENCOUNTER FOR BREAST RECONSTRUCTION FOLLOWING MASTECTOMY |
| V51.8 | OTHER AFTERCARE INVOLVING THE USE OF PLASTIC SURGERY |
| 173.30 | UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE |
| 173.31 | BASAL CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE |
| 173.32 | SQUAMOUS CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE |
| 173.39 | OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE |
| 216.3 | BENIGN NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE |
| 232.3 | CARCINOMA IN SITU OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE |
| 232.8 | CARCINOMA IN SITU OF OTHER SPECIFIED SITES OF SKIN |
| 238.2 | NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN |
| 941.27 | BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF FOREHEAD AND CHEEK |
| 941.37 | FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF FOREHEAD AND CHEEK |
| 959.01 | OTHER AND UNSPECIFIED INJURY TO HEAD |
Use 478.19 to indicate nasal obstruction
| 160.0 | MALIGNANT NEOPLASM OF NASAL CAVITIES |
| 170.0 | MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE |
| 172.3 | MALIGNANT MELANOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE |
| 173.30 | UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE |
| 173.31 | BASAL CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE |
| 173.32 | SQUAMOUS CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE |
| 173.39 | OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE |
| 195.0 | MALIGNANT NEOPLASM OF HEAD FACE AND NECK |
| 212.0 | BENIGN NEOPLASM OF NASAL CAVITIES MIDDLE EAR AND ACCESSORY SINUSES |
| 213.0 | BENIGN NEOPLASM OF BONES OF SKULL AND FACE |
| 216.3 | BENIGN NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE |
| 232.3 | CARCINOMA IN SITU OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE |
| 478.19 | OTHER DISEASE OF NASAL CAVITY AND SINUSES |
| 802.0 | CLOSED FRACTURE OF NASAL BONES |
| 802.1 | OPEN FRACTURE OF NASAL BONES |
| 702.0 | ACTINIC KERATOSIS |
| 695.3 | ROSACEA |
| 042 | HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE |
| 272.6 | LIPODYSTROPHY |
| 042 | HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE |
| 272.6 | LIPODYSTROPHY |
| 042 | HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE |
| 272.6 | LIPODYSTROPHY |
| 042 | HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE |
| 272.6 | LIPODYSTROPHY |
Diagnoses that Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity
| V50.0 | ELECTIVE HAIR TRANSPLANT FOR PURPOSES OTHER THAN REMEDYING HEALTH STATES |
| V50.1 | OTHER PLASTIC SURGERY FOR UNACCEPTABLE COSMETIC APPEARANCE |
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
General Information
The following
documentation should be made available to the Contractor upon our
request:
Reduction Mammoplasty documentation should include the evaluation and management note for the date of service and the note for the day the decision to perform surgery was made. The beneficiary's medical record must contain, and be available for review on request, the following information:
1. Height and weight.
2. Body Surface Area (BSA)
3. Clinical evaluation of the signs and/or symptoms ascribed to the macromastia, therapies prior to reduction mammoplasty and the responses to these therapies.
4. The operative report with documentation of the weight of tissue removed from each breast, obtained in the operating room.
5. The pathology report with the weight of the tissue removed from each breast.
6. Documentation of back or neck or shoulder pain from macromastia that was unrelieved by 6 months of conservative analgesia, supportive measures (garment, etc.), and physical therapy.
Abdominoplasty documentation should include the evaluation and management note in which the decision to perform surgery was made, surgical note and any notes indicating medical complications necessitating the surgery.
Rhytidectomy documentation should include the evaluation and management note in which the decision to perform surgery was made, surgical note and any notes documenting the functional impairment.
Pre-operative photographs must be made available upon Contractor request for punch graft hair transplants.
Documentation in the progress notes for tattooing, to correct color defects of the skin must indicate the prior condition i.e. post-mastectomy, trauma necessitating the reconstruction.
Appendices
Reduction Mammoplasty documentation should include the evaluation and management note for the date of service and the note for the day the decision to perform surgery was made. The beneficiary's medical record must contain, and be available for review on request, the following information:
1. Height and weight.
2. Body Surface Area (BSA)
3. Clinical evaluation of the signs and/or symptoms ascribed to the macromastia, therapies prior to reduction mammoplasty and the responses to these therapies.
4. The operative report with documentation of the weight of tissue removed from each breast, obtained in the operating room.
5. The pathology report with the weight of the tissue removed from each breast.
6. Documentation of back or neck or shoulder pain from macromastia that was unrelieved by 6 months of conservative analgesia, supportive measures (garment, etc.), and physical therapy.
Abdominoplasty documentation should include the evaluation and management note in which the decision to perform surgery was made, surgical note and any notes indicating medical complications necessitating the surgery.
Rhytidectomy documentation should include the evaluation and management note in which the decision to perform surgery was made, surgical note and any notes documenting the functional impairment.
Pre-operative photographs must be made available upon Contractor request for punch graft hair transplants.
Documentation in the progress notes for tattooing, to correct color defects of the skin must indicate the prior condition i.e. post-mastectomy, trauma necessitating the reconstruction.
See companion
article GSURG-032 Billing and Coding Instructions for Cosmetic Services
* - An asterisk indicates a revision to that section of the policy.
Sources of Information and Basis for Decision
* - An asterisk indicates a revision to that section of the policy.
Other Medicare Contractors Policies
Bogetti P, Boltri M, Spagnoli G, Dolcet M. Aesthetic Plast Surg. 2002 Jan-Feb, 26(1): 57-60 Surgical treatment of rhinophyma: a comparison of techniques
Curnier A, Choudhary S. Ann of Plast Surg, 2002 August; 49(2): 211-4 Triple approach to rhinophyma
Gupta S, Handa S, Saraswat A, Kumar B. JDermatol. 2000 Feb; 27(2): 116-20 Conventional cold excision combined with dermabrasion for rhinophyma
Jung H. Facial Plast Surgery, 1998; 14(4): 255-78 Rhinophyma: plastic surgery, rehabilitation, and long-term results
Advisory Committee Meeting Notes
Bogetti P, Boltri M, Spagnoli G, Dolcet M. Aesthetic Plast Surg. 2002 Jan-Feb, 26(1): 57-60 Surgical treatment of rhinophyma: a comparison of techniques
Curnier A, Choudhary S. Ann of Plast Surg, 2002 August; 49(2): 211-4 Triple approach to rhinophyma
Gupta S, Handa S, Saraswat A, Kumar B. JDermatol. 2000 Feb; 27(2): 116-20 Conventional cold excision combined with dermabrasion for rhinophyma
Jung H. Facial Plast Surgery, 1998; 14(4): 255-78 Rhinophyma: plastic surgery, rehabilitation, and long-term results
Advisory Committee Meeting Notes
Meeting Date:
Wisconsin: 2/12/2010
Illinois: 1/13/2010
Michigan: 1/27/2010
Minnesota: 1/14/2010
J-5 MAC
(IA,KS, MO, NE) 2/19/2010
Open LCD meeting
01/06/2010
Start Date of Comment Period
Meeting Date:
Wisconsin: 2/12/2010
Illinois: 1/13/2010
Michigan: 1/27/2010
Minnesota: 1/14/2010
J-5 MAC
(IA,KS, MO, NE) 2/19/2010
Open LCD meeting
01/06/2010
02/19/2010
End Date of Comment Period
04/05/2010
Start Date of Notice Period
10/01/2010
Revision History Number
X
Revision History Explanation
04/19/2010 - In
accordance with Section 911 of the Medicare Modernization Act of 2003,
the states of American Somoa, California, Guam, Hawaii, Nevada and
Northern Mariana Islands were removed from this LCD because claims
processing for those states are transitioning from FI
Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part
A Contractor Palmetto.
10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
15788 descriptor was changed in Group 1
15789 descriptor was changed in Group 1
15792 descriptor was changed in Group 1
15793 descriptor was changed in Group 1
G0429 descriptor was changed in Group 1
02/21/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
05/01/2011-Annual Review, no change to coverage
08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.
10/01/2011- 2012 ICD-09 code update published-Added 173.50, 173.51, 173.52, 173.59 to 19316, 19318, 19324, 19325, 19340, 19342 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371,19380,19396; added 173.30, 173.31, 173.32, 173.39 to 15775, 15776 and 30400-30450. Added CPT codes 19324 and 19350 to the CPT/HCPC's code table-no change in coverage
Reason for Change
10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
15788 descriptor was changed in Group 1
15789 descriptor was changed in Group 1
15792 descriptor was changed in Group 1
15793 descriptor was changed in Group 1
G0429 descriptor was changed in Group 1
02/21/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
05/01/2011-Annual Review, no change to coverage
08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.
10/01/2011- 2012 ICD-09 code update published-Added 173.50, 173.51, 173.52, 173.59 to 19316, 19318, 19324, 19325, 19340, 19342 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371,19380,19396; added 173.30, 173.31, 173.32, 173.39 to 15775, 15776 and 30400-30450. Added CPT codes 19324 and 19350 to the CPT/HCPC's code table-no change in coverage
This LCD has no Related Documents.
LCD Attachments
Coding and Billing Guidelines 10/01/2010 (PDF - 33 KB )
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Page Last Updated: Thursday, 20-Oct-2011 15:40:23 CDT
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