This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Reduction Mammaplasty.
Coding Information:
Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Documentation Requirements:
The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be returned.
Documentation must be available to Medicare upon request.
