LCD Reference Article Response To Comments Article

Response to Comments: Plastic Surgery

A55685

Expand All | Collapse All
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.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A55685
Original ICD-9 Article ID
Not Applicable
Article Title
Response to Comments: Plastic Surgery
Article Type
Response to Comments
Original Effective Date
10/10/2017
Revision Effective Date
N/A
Revision Ending Date
N/A
Retirement Date
N/A

CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

N/A

Article Guidance

Article Text

Noridian’s response to provider recommendations (for comment period ending 04/10/2017)

Response To Comments

Number Comment Response
1

Page 10, #6 outlines the criteria for medically indicated dermabrasion, including traumatic injury, surgery and disease, (in addition to burns).

1. Dermabrasion

Coverage will be provided when correcting defects resulting from traumatic injury, surgery, burns or disease.  Dermabrasion following burn scarring is usually accomplished in 3-4 treatments.  If the results are not optimum, other treatments may be undertaken.  Dermabrasion performed for postacne scarring is classified as cosmetic and is not covered for payment. 

However, on pages 19-34 all but only three of the covered ICD-10 codes are for burns or corrosion.

Group 1: Paragraph

Providers are to use the ICD-10-CM® Code that most correctly describes the condition for which any procedure is performed.

These are the only covered ICD-10-CM® codes that support medical necessity:

Dermabrasion (CPT Codes 15780-15783)

Group 1: Codes

There are no covered ICD-10® codes listed for traumatic injury, surgery or disease (other than rhinophyma, perioral dermatitis and rosacea).

Additional ICD-10® codes for correcting defects resulting from traumatic injury, surgery and other disease need to be added.

 

 

 

Dermabrasion is infrequently used in places other than the head and neck (including face). Other trauma generally does not require dermabrasion.  In those rare occasions Noridian will gladly review a redetermination request with clinical records and where necessary, peer reviewed scientific literature, that support the need for dermabrasion in the treatment of the traumatic injury.

2

We would like to submit the following comments on Proposed/Draft Plastic Surgery LCD DL37020.  Thank-you for the opportunity to comment on the draft LCD.

Group 2: Abdominal Lipectomy/Panniculectomy

1. The Indications of Coverage section for Abdominal Lipectomy/Panniculectomy, includes the following indications: When surgery is performed to alleviate such complicating factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intritrigal dermatitis, such surgery is considered reconstructive.

Please consider adding the following diagnosis codes to Group 2 of the policy for the above mentioned indications:

Code

Description

M79.3

Panniculitis, unspecified

L53.8

Other specified erythematous conditions

L53.9

Erythematous condition, unspecified

L03.818

Cellulitis of other Sites

L03.311

Cellulitis of abdominal wall

R26.2

Difficulty in walking, not elsewhere classified

R26.89

Other abnormalities of gait and mobility

G89.29

Other chronic pain

L30.9

Dermatitis, unspecified

L30.8

Other specified dermatitis

 

Group 3: Reconstructive Breast Surgery

  1. Unable to locate any Indications of Coverage for this section, however; given the nature of the procedures, please consider adding the following diagnosis codes to Group 3 of the policy.

Code

Description

Z42.1

Encounter for breast reconstruction following mastectomy

C50.911

Malignant neoplasm of unspecified site of right female breast

C50.912

Malignant neoplasm of unspecified site of left female breast

C50.921

Malignant neoplasm of unspecified site of right male breast

C50.922

Malignant neoplasm of unspecified site of left male breast

D05.91

Unspecified type of carcinoma in situ of right breast

D05.92

Unspecified type of carcinoma in situ of left breast

D49.3

Neoplasm of unspecified behavior of breast

N65.0

Deformity of reconstructed breast

T85.79XA

Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter

T85.79XD

Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, subsequent encounter

T85.79XS

Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, sequela

 

Group 4 & 5: Reduction Mammaplasty

  1. Please clarify the wording in Group 4 & 5, there appears to be conflicting requirements in the underlined parts of this section.

           Group 4 Paragraph: Reduction Mammaplasty (CPT Code 19318)

           Three diagnoses are required for payment (One primary and two secondary).

           Primary ICD-10-CM:

           Group 4 Codes:

           ICD-10 Codes Description

           N62* Hypertrophy of breast

           N65.1* Disproportion of reconstructed breast

           Group 4 Medical Necessity ICD-10 Codes Asterisk Explanation: *Primary diagnosis N62 or N65.1 must

            be billed with one of the secondary diagnoses: listed in Group 5 Secondary Codes for Reduction Mammaplasty

 

           Group 5 Paragraph: Secondary ICD-10-CMs to be used when billing one of the reduction mammaplasty primary codes.

           Correct coding for this procedure requires two secondary ICD-10-CM codes from Group 5 (this section) and one 

           of the primary ICD-10-CM codes from Group 4.

 

2. Per the Reduction Mammaplasty Indications included on the policy:

  1. Reduction mammaplasty is covered by Medicare when it is performed:

            i. 2. To reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after breast cancer surgery. 

     Diagnosis code N65.1-disproportion of reconstructed breast is already a covered diagnosis code on the policy.

     However; currently  how  the policy is written, my understanding is that in addition to the N65.1 we would need two secondary diagnosis codes in

     order to be considered medically necessary.

     Request: When Mammaplasty is done to reduce the size of a normal breast to bring it into symmetry with a breast reconstructed      

     after breast cancer surgery: Please consider allowing N65.1 to be the only diagnosis code needed for medical necessity. Please also 

     consider adding an asterisks notation to N65.1 to clarify that use N65.1 should be used to indicate a mammaplasty to reduce the size of a

     normal breast to bring it into symmetry with a breast reconstructed after cancer surgery.

3. The Indications of Coverage section for Reduction Mammaplasty, includes the following indications:

  1. Muscle strain such as backache, neck pain, shoulder pain and less often upper extremity peripheral neuropathy and/or headache;
  2. Problems associated with excess breast weight and brassiere support such as clavicular bra strap grooves;

     Please consider adding the following diagnosis codes to Group 4 & 5 of the policy for the above mentioned indications.

Code

Description

N64.1

Fat necrosis of breast

N64.81

Ptosis of breast

N65.1

Disproportion of reconstructed breast

R21

Rash and other nonspecific skin eruption

M25.519

Pain in unspecified shoulder

G44.209

Tension-type headache, unspecified, not intractable

G44.229

Chronic tension-type headache, not intractable

 

Group 6 Paragraph: Rhinoplasty

  1. The Indications of Coverage section for Rhinoplasty and Reconstructive Nasal Surgery, includes the following indications: Reconstructive nasal surgery is generally directed to improve nasal respiratory function (e.g., airway obstruction or stricture, synechia formation); repair defects caused by trauma (e.g., nasoseptal deviation, intranasal cicatrix, dislocated nasal bone fractures, turbinate hypertrophy); treat congenital anatomic abnormalities (e.g., cleft lip nasal deformities, choanal atresia, oronasal or oromaxillary fistula); treat nasal cutaneous disease (e.g., rhinophyma, dermoid cyst); or to replace nasal tissue lost after tumor ablative surgery.

        Please consider adding the following diagnosis codes to Group 6 of the policy for the above mentioned indications.

 

Code

Description

C44.301

Unspecified malignant neoplasm of skin of nose

C44.309

Unspecified malignant 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

J34.2

Deviated nasal septum

 

 

Noridian appreciates the following comments. Each area is addressed below.

Group 2: Abdominal Lipectomy/Panniculectomy

  • M79.3 does not meet the requirements for surgical intervention.

  • L53.8, L53.9 and L03.818, L30.8, and L30.9 are non-specific and other specific codes exist

  • L03.311 will be added.

  • R26.2, R26.89 and G89.29 each describe findings that Noridian expect to be rare and therein will require a redetermination with supporting clinical records.

Group 3: Reconstructive Breast Surgery

  • Z42.1, N65.0 and T85.79Xx will be added

  • C50.9xx codes are unspecified and not acceptable for this policy.

  • D05.9x codes are unspecified and not acceptable for this policy. Noridian expects the surgeon to known what type of CIS is present and use the respective code.

Group 4 & 5: Reduction Mammoplasty

      4. Three diagnoses are required for payment (One primary and two secondary)

      5. The coding section has been amended to indicate that N65.1 may be used alone when surgery on the unaffected

           breast is being performed to restore symmetry following breast cancer surgery.       

        6. Noridian will not be adding the codes requested at this time as the current ICD-10 codes set is sufficient.

Group 6 Paragraph: Rhinoplasty

       2. The requested codes are either unspecified (C44.xxx) or do not of themselves demonstrate a covered reason for a

            rhinoplasty.

 

N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

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

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

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

Revision History Information

Revision History Date Revision History Number Revision History Explanation
N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
N/A
Related National Coverage Documents
N/A
SAD Process URL 1
N/A
SAD Process URL 2
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
08/11/2017 10/10/2017 - N/A Currently in Effect You are here

Keywords

  • Plastic
  • Surgery
  • 15780
  • 15781
  • 15782
  • 15783
  • 15830
  • 15832
  • 15833
  • 15834
  • 15835
  • 15836
  • 15837
  • 15838
  • 15839
  • 15847
  • 15876
  • 15877
  • 15878
  • 15879
  • 19316
  • 19318
  • 19324
  • 19325
  • 19328
  • 19330
  • 19340
  • 19342
  • 19350
  • 19355
  • 19357
  • 19361
  • 19364
  • 19366
  • 19367
  • 19368
  • 19369
  • 19370
  • 19371
  • 19380
  • 19396
  • 30400
  • 30410
  • 30420
  • 30430
  • 30435
  • 30450