LCD Reference Article Billing and Coding Article

Billing and Coding: Plastic Surgery

A57222

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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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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A57222
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Plastic Surgery
Article Type
Billing and Coding
Original Effective Date
10/01/2019
Revision Effective Date
10/01/2023
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

Title XVIII of the Social Security Act, §1862(a)(1)(A). Allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

Title XVIII of the Social Security Act, §1833(e). Prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.

Title XVIII of the Social Security Act, §1862(a)(10). Coverage of cosmetic surgery is discussed.

Medicare On-Line Manual System, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, §§10, 120, and 180.

Medicare On-Line Manual System, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §§140.2 and 140.4.

Article Guidance

Article Text

The following coding and billing guidance is to be used with its associated Local coverage determination.

Cosmetic surgery is performed to reshape normal structures of the body, for the purpose of improving the patient’s appearance and self-esteem. Per IOM 100-02 Chapter 16, cosmetic surgery and expenses incurred in connection with such surgery are not covered. This exclusion does not apply to surgery in connection with the treatment of severe burns, facial repair following auto trauma, or similar surgeries for therapeutic purposes or reconstruction.

For Reduction Mammoplasty:
1. Physicians should document the severity of the symptoms of breast hypertrophy and impact on health related quality of life as measured by an accepted breast specific questionnaire.
The beneficiary's medical record must contain the following information and be made available to any authorized Medicare auditor upon request:

  • Height and weight
  • Clinical evaluation of the signs and/or symptoms ascribed to the macromastia, therapies prior to reduction mammoplasty and the responses to these therapies.
  • 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.

2. Reasons for denial include:

  1. Surgery is deemed or later determined to be cosmetic in nature. Breast surgery for uncomplicated macromastia, pendulous breasts, or to correct otherwise uncomplicated nipple inversions will be considered cosmetic and not reasonable and necessary
  2. Failure to clearly document persistent signs and symptoms despite a reasonable trial of conservative therapy for a reasonable length of time.
  3. Services submitted without a listed diagnosis (ICD-10-CM) code supporting medical necessity
  4. Use of any ICD-10-CM codes not listed in the ICD-10-CM Codes That Support Medical Necessity Section below.

For all procedures noted within this policy:
The medical record must be made available to Medicare or a Medicare auditor upon request.

The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

Services billed with a diagnosis code that is not listed in the ICD-10-CM Codes That Support Medical Necessity section of this policy may be considered at redetermination on a case-by-case basis.

When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services may be denied as not reasonable and necessary.

When requesting a written redetermination, providers must include all relevant documentation with the request. Failure to include such items will likely result in an unfavorable determination. While not required, high quality photographs may be useful in determining medical necessity and may be submitted when the provider feels it is appropriate to do so.




 

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
999x Not Applicable
N/A

Revenue Codes

Code Description
99999 Not Applicable
N/A

CPT/HCPCS Codes

Group 1

(43 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
15780 DERMABRASION; TOTAL FACE (EG, FOR ACNE SCARRING, FINE WRINKLING, RHYTIDS, GENERAL KERATOSIS)
15781 DERMABRASION; SEGMENTAL, FACE
15782 DERMABRASION; REGIONAL, OTHER THAN FACE
15783 DERMABRASION; SUPERFICIAL, ANY SITE (EG, TATTOO REMOVAL)
15830 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY
15832 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); THIGH
15833 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); LEG
15834 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); HIP
15835 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); BUTTOCK
15836 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ARM
15837 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); FOREARM OR HAND
15838 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); SUBMENTAL FAT PAD
15839 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA
15847 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY), ABDOMEN (EG, ABDOMINOPLASTY) (INCLUDES UMBILICAL TRANSPOSITION AND FASCIAL PLICATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
15876 SUCTION ASSISTED LIPECTOMY; HEAD AND NECK
15877 SUCTION ASSISTED LIPECTOMY; TRUNK
15878 SUCTION ASSISTED LIPECTOMY; UPPER EXTREMITY
15879 SUCTION ASSISTED LIPECTOMY; LOWER EXTREMITY
19316 MASTOPEXY
19318 BREAST REDUCTION
19325 BREAST AUGMENTATION WITH IMPLANT
19328 REMOVAL OF INTACT BREAST IMPLANT
19330 REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)
19340 INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE)
19342 INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY
19350 NIPPLE/AREOLA RECONSTRUCTION
19355 CORRECTION OF INVERTED NIPPLES
19357 TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)
19361 BREAST RECONSTRUCTION; WITH LATISSIMUS DORSI FLAP
19364 BREAST RECONSTRUCTION; WITH FREE FLAP (EG, FTRAM, DIEP, SIEA, GAP FLAP)
19367 BREAST RECONSTRUCTION; WITH SINGLE-PEDICLED TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS (TRAM) FLAP
19368 BREAST RECONSTRUCTION; WITH SINGLE-PEDICLED TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS (TRAM) FLAP, REQUIRING SEPARATE MICROVASCULAR ANASTOMOSIS (SUPERCHARGING)
19369 BREAST RECONSTRUCTION; WITH BIPEDICLED TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS (TRAM) FLAP
19370 REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY
19371 PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS
19380 REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)
19396 PREPARATION OF MOULAGE FOR CUSTOM BREAST IMPLANT
30400 RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES AND/OR ELEVATION OF NASAL TIP
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)
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

(387 Codes)
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
Code Description
L71.0 Perioral dermatitis
L71.1 Rhinophyma
L71.8 Other rosacea
T20.311A Burn of third degree of right ear [any part, except ear drum], initial encounter
T20.311D Burn of third degree of right ear [any part, except ear drum], subsequent encounter
T20.311S Burn of third degree of right ear [any part, except ear drum], sequela
T20.312A Burn of third degree of left ear [any part, except ear drum], initial encounter
T20.312D Burn of third degree of left ear [any part, except ear drum], subsequent encounter
T20.312S Burn of third degree of left ear [any part, except ear drum], sequela
T20.32XA Burn of third degree of lip(s), initial encounter
T20.32XD Burn of third degree of lip(s), subsequent encounter
T20.32XS Burn of third degree of lip(s), sequela
T20.33XA Burn of third degree of chin, initial encounter
T20.33XD Burn of third degree of chin, subsequent encounter
T20.33XS Burn of third degree of chin, sequela
T20.34XA Burn of third degree of nose (septum), initial encounter
T20.34XD Burn of third degree of nose (septum), subsequent encounter
T20.34XS Burn of third degree of nose (septum), sequela
T20.35XA Burn of third degree of scalp [any part], initial encounter
T20.35XD Burn of third degree of scalp [any part], subsequent encounter
T20.35XS Burn of third degree of scalp [any part], sequela
T20.36XA Burn of third degree of forehead and cheek, initial encounter
T20.36XD Burn of third degree of forehead and cheek, subsequent encounter
T20.36XS Burn of third degree of forehead and cheek, sequela
T20.37XA Burn of third degree of neck, initial encounter
T20.37XD Burn of third degree of neck, subsequent encounter
T20.37XS Burn of third degree of neck, sequela
T20.39XA Burn of third degree of multiple sites of head, face, and neck, initial encounter
T20.39XD Burn of third degree of multiple sites of head, face, and neck, subsequent encounter
T20.39XS Burn of third degree of multiple sites of head, face, and neck, sequela
T20.711A Corrosion of third degree of right ear [any part, except ear drum], initial encounter
T20.711D Corrosion of third degree of right ear [any part, except ear drum], subsequent encounter
T20.711S Corrosion of third degree of right ear [any part, except ear drum], sequela
T20.712A Corrosion of third degree of left ear [any part, except ear drum], initial encounter
T20.712D Corrosion of third degree of left ear [any part, except ear drum], subsequent encounter
T20.712S Corrosion of third degree of left ear [any part, except ear drum], sequela
T20.72XA Corrosion of third degree of lip(s), initial encounter
T20.72XD Corrosion of third degree of lip(s), subsequent encounter
T20.72XS Corrosion of third degree of lip(s), sequela
T20.73XA Corrosion of third degree of chin, initial encounter
T20.73XD Corrosion of third degree of chin, subsequent encounter
T20.73XS Corrosion of third degree of chin, sequela
T20.74XA Corrosion of third degree of nose (septum), initial encounter
T20.74XD Corrosion of third degree of nose (septum), subsequent encounter
T20.74XS Corrosion of third degree of nose (septum), sequela
T20.75XA Corrosion of third degree of scalp [any part], initial encounter
T20.75XD Corrosion of third degree of scalp [any part], subsequent encounter
T20.75XS Corrosion of third degree of scalp [any part], sequela
T20.76XA Corrosion of third degree of forehead and cheek, initial encounter
T20.76XD Corrosion of third degree of forehead and cheek, subsequent encounter
T20.76XS Corrosion of third degree of forehead and cheek, sequela
T20.77XA Corrosion of third degree of neck, initial encounter
T20.77XD Corrosion of third degree of neck, subsequent encounter
T20.77XS Corrosion of third degree of neck, sequela
T20.79XA Corrosion of third degree of multiple sites of head, face, and neck, initial encounter
T20.79XD Corrosion of third degree of multiple sites of head, face, and neck, subsequent encounter
T20.79XS Corrosion of third degree of multiple sites of head, face, and neck, sequela
T21.31XA Burn of third degree of chest wall, initial encounter
T21.31XD Burn of third degree of chest wall, subsequent encounter
T21.31XS Burn of third degree of chest wall, sequela
T21.32XA Burn of third degree of abdominal wall, initial encounter
T21.32XD Burn of third degree of abdominal wall, subsequent encounter
T21.32XS Burn of third degree of abdominal wall, sequela
T21.33XA Burn of third degree of upper back, initial encounter
T21.33XD Burn of third degree of upper back, subsequent encounter
T21.33XS Burn of third degree of upper back, sequela
T21.34XA Burn of third degree of lower back, initial encounter
T21.34XD Burn of third degree of lower back, subsequent encounter
T21.34XS Burn of third degree of lower back, sequela
T21.35XA Burn of third degree of buttock, initial encounter
T21.35XD Burn of third degree of buttock, subsequent encounter
T21.35XS Burn of third degree of buttock, sequela
T21.36XA Burn of third degree of male genital region, initial encounter
T21.36XD Burn of third degree of male genital region, subsequent encounter
T21.36XS Burn of third degree of male genital region, sequela
T21.37XA Burn of third degree of female genital region, initial encounter
T21.37XD Burn of third degree of female genital region, subsequent encounter
T21.37XS Burn of third degree of female genital region, sequela
T21.39XA Burn of third degree of other site of trunk, initial encounter
T21.39XD Burn of third degree of other site of trunk, subsequent encounter
T21.39XS Burn of third degree of other site of trunk, sequela
T21.71XA Corrosion of third degree of chest wall, initial encounter
T21.71XD Corrosion of third degree of chest wall, subsequent encounter
T21.71XS Corrosion of third degree of chest wall, sequela
T21.72XA Corrosion of third degree of abdominal wall, initial encounter
T21.72XD Corrosion of third degree of abdominal wall, subsequent encounter
T21.72XS Corrosion of third degree of abdominal wall, sequela
T21.73XA Corrosion of third degree of upper back, initial encounter
T21.73XD Corrosion of third degree of upper back, subsequent encounter
T21.73XS Corrosion of third degree of upper back, sequela
T21.74XA Corrosion of third degree of lower back, initial encounter
T21.74XD Corrosion of third degree of lower back, subsequent encounter
T21.74XS Corrosion of third degree of lower back, sequela
T21.75XA Corrosion of third degree of buttock, initial encounter
T21.75XD Corrosion of third degree of buttock, subsequent encounter
T21.75XS Corrosion of third degree of buttock, sequela
T21.76XA Corrosion of third degree of male genital region, initial encounter
T21.76XD Corrosion of third degree of male genital region, subsequent encounter
T21.76XS Corrosion of third degree of male genital region, sequela
T21.77XA Corrosion of third degree of female genital region, initial encounter
T21.77XD Corrosion of third degree of female genital region, subsequent encounter
T21.77XS Corrosion of third degree of female genital region, sequela
T21.79XA Corrosion of third degree of other site of trunk, initial encounter
T21.79XD Corrosion of third degree of other site of trunk, subsequent encounter
T21.79XS Corrosion of third degree of other site of trunk, sequela
T22.311A Burn of third degree of right forearm, initial encounter
T22.311D Burn of third degree of right forearm, subsequent encounter
T22.311S Burn of third degree of right forearm, sequela
T22.312A Burn of third degree of left forearm, initial encounter
T22.312D Burn of third degree of left forearm, subsequent encounter
T22.312S Burn of third degree of left forearm, sequela
T22.321A Burn of third degree of right elbow, initial encounter
T22.321D Burn of third degree of right elbow, subsequent encounter
T22.321S Burn of third degree of right elbow, sequela
T22.322A Burn of third degree of left elbow, initial encounter
T22.322D Burn of third degree of left elbow, subsequent encounter
T22.322S Burn of third degree of left elbow, sequela
T22.331A Burn of third degree of right upper arm, initial encounter
T22.331D Burn of third degree of right upper arm, subsequent encounter
T22.331S Burn of third degree of right upper arm, sequela
T22.332A Burn of third degree of left upper arm, initial encounter
T22.332D Burn of third degree of left upper arm, subsequent encounter
T22.332S Burn of third degree of left upper arm, sequela
T22.341A Burn of third degree of right axilla, initial encounter
T22.341D Burn of third degree of right axilla, subsequent encounter
T22.341S Burn of third degree of right axilla, sequela
T22.342A Burn of third degree of left axilla, initial encounter
T22.342D Burn of third degree of left axilla, subsequent encounter
T22.342S Burn of third degree of left axilla, sequela
T22.351A Burn of third degree of right shoulder, initial encounter
T22.351D Burn of third degree of right shoulder, subsequent encounter
T22.351S Burn of third degree of right shoulder, sequela
T22.352A Burn of third degree of left shoulder, initial encounter
T22.352D Burn of third degree of left shoulder, subsequent encounter
T22.352S Burn of third degree of left shoulder, sequela
T22.361A Burn of third degree of right scapular region, initial encounter
T22.361D Burn of third degree of right scapular region, subsequent encounter
T22.361S Burn of third degree of right scapular region, sequela
T22.362A Burn of third degree of left scapular region, initial encounter
T22.362D Burn of third degree of left scapular region, subsequent encounter
T22.362S Burn of third degree of left scapular region, sequela
T22.391A Burn of third degree of multiple sites of right shoulder and upper limb, except wrist and hand, initial encounter
T22.391D Burn of third degree of multiple sites of right shoulder and upper limb, except wrist and hand, subsequent encounter
T22.391S Burn of third degree of multiple sites of right shoulder and upper limb, except wrist and hand, sequela
T22.392A Burn of third degree of multiple sites of left shoulder and upper limb, except wrist and hand, initial encounter
T22.392D Burn of third degree of multiple sites of left shoulder and upper limb, except wrist and hand, subsequent encounter
T22.392S Burn of third degree of multiple sites of left shoulder and upper limb, except wrist and hand, sequela
T22.711A Corrosion of third degree of right forearm, initial encounter
T22.711D Corrosion of third degree of right forearm, subsequent encounter
T22.711S Corrosion of third degree of right forearm, sequela
T22.712A Corrosion of third degree of left forearm, initial encounter
T22.712D Corrosion of third degree of left forearm, subsequent encounter
T22.712S Corrosion of third degree of left forearm, sequela
T22.721A Corrosion of third degree of right elbow, initial encounter
T22.721D Corrosion of third degree of right elbow, subsequent encounter
T22.721S Corrosion of third degree of right elbow, sequela
T22.722A Corrosion of third degree of left elbow, initial encounter
T22.722D Corrosion of third degree of left elbow, subsequent encounter
T22.722S Corrosion of third degree of left elbow, sequela
T22.731A Corrosion of third degree of right upper arm, initial encounter
T22.731D Corrosion of third degree of right upper arm, subsequent encounter
T22.731S Corrosion of third degree of right upper arm, sequela
T22.732A Corrosion of third degree of left upper arm, initial encounter
T22.732D Corrosion of third degree of left upper arm, subsequent encounter
T22.732S Corrosion of third degree of left upper arm, sequela
T22.741A Corrosion of third degree of right axilla, initial encounter
T22.741D Corrosion of third degree of right axilla, subsequent encounter
T22.741S Corrosion of third degree of right axilla, sequela
T22.742A Corrosion of third degree of left axilla, initial encounter
T22.742D Corrosion of third degree of left axilla, subsequent encounter
T22.742S Corrosion of third degree of left axilla, sequela
T22.751A Corrosion of third degree of right shoulder, initial encounter
T22.751D Corrosion of third degree of right shoulder, subsequent encounter
T22.751S Corrosion of third degree of right shoulder, sequela
T22.752A Corrosion of third degree of left shoulder, initial encounter
T22.752D Corrosion of third degree of left shoulder, subsequent encounter
T22.752S Corrosion of third degree of left shoulder, sequela
T22.761A Corrosion of third degree of right scapular region, initial encounter
T22.761D Corrosion of third degree of right scapular region, subsequent encounter
T22.761S Corrosion of third degree of right scapular region, sequela
T22.762A Corrosion of third degree of left scapular region, initial encounter
T22.762D Corrosion of third degree of left scapular region, subsequent encounter
T22.762S Corrosion of third degree of left scapular region, sequela
T22.791A Corrosion of third degree of multiple sites of right shoulder and upper limb, except wrist and hand, initial encounter
T22.791D Corrosion of third degree of multiple sites of right shoulder and upper limb, except wrist and hand, subsequent encounter
T22.791S Corrosion of third degree of multiple sites of right shoulder and upper limb, except wrist and hand, sequela
T22.792A Corrosion of third degree of multiple sites of left shoulder and upper limb, except wrist and hand, initial encounter
T22.792D Corrosion of third degree of multiple sites of left shoulder and upper limb, except wrist and hand, subsequent encounter
T22.792S Corrosion of third degree of multiple sites of left shoulder and upper limb, except wrist and hand, sequela
T23.311A Burn of third degree of right thumb (nail), initial encounter
T23.311D Burn of third degree of right thumb (nail), subsequent encounter
T23.311S Burn of third degree of right thumb (nail), sequela
T23.312A Burn of third degree of left thumb (nail), initial encounter
T23.312D Burn of third degree of left thumb (nail), subsequent encounter
T23.312S Burn of third degree of left thumb (nail), sequela
T23.321A Burn of third degree of single right finger (nail) except thumb, initial encounter
T23.321D Burn of third degree of single right finger (nail) except thumb, subsequent encounter
T23.321S Burn of third degree of single right finger (nail) except thumb, sequela
T23.322A Burn of third degree of single left finger (nail) except thumb, initial encounter
T23.322D Burn of third degree of single left finger (nail) except thumb, subsequent encounter
T23.322S Burn of third degree of single left finger (nail) except thumb, sequela
T23.331A Burn of third degree of multiple right fingers (nail), not including thumb, initial encounter
T23.331D Burn of third degree of multiple right fingers (nail), not including thumb, subsequent encounter
T23.331S Burn of third degree of multiple right fingers (nail), not including thumb, sequela
T23.332A Burn of third degree of multiple left fingers (nail), not including thumb, initial encounter
T23.332D Burn of third degree of multiple left fingers (nail), not including thumb, subsequent encounter
T23.332S Burn of third degree of multiple left fingers (nail), not including thumb, sequela
T23.341A Burn of third degree of multiple right fingers (nail), including thumb, initial encounter
T23.341D Burn of third degree of multiple right fingers (nail), including thumb, subsequent encounter
T23.341S Burn of third degree of multiple right fingers (nail), including thumb, sequela
T23.342A Burn of third degree of multiple left fingers (nail), including thumb, initial encounter
T23.342D Burn of third degree of multiple left fingers (nail), including thumb, subsequent encounter
T23.342S Burn of third degree of multiple left fingers (nail), including thumb, sequela
T23.351A Burn of third degree of right palm, initial encounter
T23.351D Burn of third degree of right palm, subsequent encounter
T23.351S Burn of third degree of right palm, sequela
T23.352A Burn of third degree of left palm, initial encounter
T23.352D Burn of third degree of left palm, subsequent encounter
T23.352S Burn of third degree of left palm, sequela
T23.361A Burn of third degree of back of right hand, initial encounter
T23.361D Burn of third degree of back of right hand, subsequent encounter
T23.361S Burn of third degree of back of right hand, sequela
T23.362A Burn of third degree of back of left hand, initial encounter
T23.362D Burn of third degree of back of left hand, subsequent encounter
T23.362S Burn of third degree of back of left hand, sequela
T23.371A Burn of third degree of right wrist, initial encounter
T23.371D Burn of third degree of right wrist, subsequent encounter
T23.371S Burn of third degree of right wrist, sequela
T23.372A Burn of third degree of left wrist, initial encounter
T23.372D Burn of third degree of left wrist, subsequent encounter
T23.372S Burn of third degree of left wrist, sequela
T23.391A Burn of third degree of multiple sites of right wrist and hand, initial encounter
T23.391D Burn of third degree of multiple sites of right wrist and hand, subsequent encounter
T23.391S Burn of third degree of multiple sites of right wrist and hand, sequela
T23.392A Burn of third degree of multiple sites of left wrist and hand, initial encounter
T23.392D Burn of third degree of multiple sites of left wrist and hand, subsequent encounter
T23.392S Burn of third degree of multiple sites of left wrist and hand, sequela
T23.711A Corrosion of third degree of right thumb (nail), initial encounter
T23.711D Corrosion of third degree of right thumb (nail), subsequent encounter
T23.711S Corrosion of third degree of right thumb (nail), sequela
T23.712A Corrosion of third degree of left thumb (nail), initial encounter
T23.712D Corrosion of third degree of left thumb (nail), subsequent encounter
T23.712S Corrosion of third degree of left thumb (nail), sequela
T23.721A Corrosion of third degree of single right finger (nail) except thumb, initial encounter
T23.721D Corrosion of third degree of single right finger (nail) except thumb, subsequent encounter
T23.721S Corrosion of third degree of single right finger (nail) except thumb, sequela
T23.722A Corrosion of third degree of single left finger (nail) except thumb, initial encounter
T23.722D Corrosion of third degree of single left finger (nail) except thumb, subsequent encounter
T23.722S Corrosion of third degree of single left finger (nail) except thumb, sequela
T23.731A Corrosion of third degree of multiple right fingers (nail), not including thumb, initial encounter
T23.731D Corrosion of third degree of multiple right fingers (nail), not including thumb, subsequent encounter
T23.731S Corrosion of third degree of multiple right fingers (nail), not including thumb, sequela
T23.732A Corrosion of third degree of multiple left fingers (nail), not including thumb, initial encounter
T23.732D Corrosion of third degree of multiple left fingers (nail), not including thumb, subsequent encounter
T23.732S Corrosion of third degree of multiple left fingers (nail), not including thumb, sequela
T23.741A Corrosion of third degree of multiple right fingers (nail), including thumb, initial encounter
T23.741D Corrosion of third degree of multiple right fingers (nail), including thumb, subsequent encounter
T23.741S Corrosion of third degree of multiple right fingers (nail), including thumb, sequela
T23.742A Corrosion of third degree of multiple left fingers (nail), including thumb, initial encounter
T23.742D Corrosion of third degree of multiple left fingers (nail), including thumb, subsequent encounter
T23.742S Corrosion of third degree of multiple left fingers (nail), including thumb, sequela
T23.751A Corrosion of third degree of right palm, initial encounter
T23.751D Corrosion of third degree of right palm, subsequent encounter
T23.751S Corrosion of third degree of right palm, sequela
T23.752A Corrosion of third degree of left palm, initial encounter
T23.752D Corrosion of third degree of left palm, subsequent encounter
T23.752S Corrosion of third degree of left palm, sequela
T23.761A Corrosion of third degree of back of right hand, initial encounter
T23.761D Corrosion of third degree of back of right hand, subsequent encounter
T23.761S Corrosion of third degree of back of right hand, sequela
T23.762A Corrosion of third degree of back of left hand, initial encounter
T23.762D Corrosion of third degree of back of left hand, subsequent encounter
T23.762S Corrosion of third degree of back of left hand, sequela
T23.771A Corrosion of third degree of right wrist, initial encounter
T23.771D Corrosion of third degree of right wrist, subsequent encounter
T23.771S Corrosion of third degree of right wrist, sequela
T23.772A Corrosion of third degree of left wrist, initial encounter
T23.772D Corrosion of third degree of left wrist, subsequent encounter
T23.772S Corrosion of third degree of left wrist, sequela
T23.791A Corrosion of third degree of multiple sites of right wrist and hand, initial encounter
T23.791D Corrosion of third degree of multiple sites of right wrist and hand, subsequent encounter
T23.791S Corrosion of third degree of multiple sites of right wrist and hand, sequela
T23.792A Corrosion of third degree of multiple sites of left wrist and hand, initial encounter
T23.792D Corrosion of third degree of multiple sites of left wrist and hand, subsequent encounter
T23.792S Corrosion of third degree of multiple sites of left wrist and hand, sequela
T24.311A Burn of third degree of right thigh, initial encounter
T24.311D Burn of third degree of right thigh, subsequent encounter
T24.311S Burn of third degree of right thigh, sequela
T24.312A Burn of third degree of left thigh, initial encounter
T24.312D Burn of third degree of left thigh, subsequent encounter
T24.312S Burn of third degree of left thigh, sequela
T24.321A Burn of third degree of right knee, initial encounter
T24.321D Burn of third degree of right knee, subsequent encounter
T24.321S Burn of third degree of right knee, sequela
T24.322A Burn of third degree of left knee, initial encounter
T24.322D Burn of third degree of left knee, subsequent encounter
T24.322S Burn of third degree of left knee, sequela
T24.331A Burn of third degree of right lower leg, initial encounter
T24.331D Burn of third degree of right lower leg, subsequent encounter
T24.331S Burn of third degree of right lower leg, sequela
T24.332A Burn of third degree of left lower leg, initial encounter
T24.332D Burn of third degree of left lower leg, subsequent encounter
T24.332S Burn of third degree of left lower leg, sequela
T24.391A Burn of third degree of multiple sites of right lower limb, except ankle and foot, initial encounter
T24.391D Burn of third degree of multiple sites of right lower limb, except ankle and foot, subsequent encounter
T24.391S Burn of third degree of multiple sites of right lower limb, except ankle and foot, sequela
T24.392A Burn of third degree of multiple sites of left lower limb, except ankle and foot, initial encounter
T24.392D Burn of third degree of multiple sites of left lower limb, except ankle and foot, subsequent encounter
T24.392S Burn of third degree of multiple sites of left lower limb, except ankle and foot, sequela
T24.711A Corrosion of third degree of right thigh, initial encounter
T24.711D Corrosion of third degree of right thigh, subsequent encounter
T24.711S Corrosion of third degree of right thigh, sequela
T24.712A Corrosion of third degree of left thigh, initial encounter
T24.712D Corrosion of third degree of left thigh, subsequent encounter
T24.712S Corrosion of third degree of left thigh, sequela
T24.721A Corrosion of third degree of right knee, initial encounter
T24.721D Corrosion of third degree of right knee, subsequent encounter
T24.721S Corrosion of third degree of right knee, sequela
T24.722A Corrosion of third degree of left knee, initial encounter
T24.722D Corrosion of third degree of left knee, subsequent encounter
T24.722S Corrosion of third degree of left knee, sequela
T24.731A Corrosion of third degree of right lower leg, initial encounter
T24.731D Corrosion of third degree of right lower leg, subsequent encounter
T24.731S Corrosion of third degree of right lower leg, sequela
T24.732A Corrosion of third degree of left lower leg, initial encounter
T24.732D Corrosion of third degree of left lower leg, subsequent encounter
T24.732S Corrosion of third degree of left lower leg, sequela
T24.791A Corrosion of third degree of multiple sites of right lower limb, except ankle and foot, initial encounter
T24.791D Corrosion of third degree of multiple sites of right lower limb, except ankle and foot, subsequent encounter
T24.791S Corrosion of third degree of multiple sites of right lower limb, except ankle and foot, sequela
T24.792A Corrosion of third degree of multiple sites of left lower limb, except ankle and foot, initial encounter
T24.792D Corrosion of third degree of multiple sites of left lower limb, except ankle and foot, subsequent encounter
T24.792S Corrosion of third degree of multiple sites of left lower limb, except ankle and foot, sequela
T25.311A Burn of third degree of right ankle, initial encounter
T25.311D Burn of third degree of right ankle, subsequent encounter
T25.311S Burn of third degree of right ankle, sequela
T25.312A Burn of third degree of left ankle, initial encounter
T25.312D Burn of third degree of left ankle, subsequent encounter
T25.312S Burn of third degree of left ankle, sequela
T25.321A Burn of third degree of right foot, initial encounter
T25.321D Burn of third degree of right foot, subsequent encounter
T25.321S Burn of third degree of right foot, sequela
T25.322A Burn of third degree of left foot, initial encounter
T25.322D Burn of third degree of left foot, subsequent encounter
T25.322S Burn of third degree of left foot, sequela
T25.331A Burn of third degree of right toe(s) (nail), initial encounter
T25.331D Burn of third degree of right toe(s) (nail), subsequent encounter
T25.331S Burn of third degree of right toe(s) (nail), sequela
T25.332A Burn of third degree of left toe(s) (nail), initial encounter
T25.332D Burn of third degree of left toe(s) (nail), subsequent encounter
T25.332S Burn of third degree of left toe(s) (nail), sequela
T25.391A Burn of third degree of multiple sites of right ankle and foot, initial encounter
T25.391D Burn of third degree of multiple sites of right ankle and foot, subsequent encounter
T25.391S Burn of third degree of multiple sites of right ankle and foot, sequela
T25.392A Burn of third degree of multiple sites of left ankle and foot, initial encounter
T25.392D Burn of third degree of multiple sites of left ankle and foot, subsequent encounter
T25.392S Burn of third degree of multiple sites of left ankle and foot, sequela
T25.711A Corrosion of third degree of right ankle, initial encounter
T25.711D Corrosion of third degree of right ankle, subsequent encounter
T25.711S Corrosion of third degree of right ankle, sequela
T25.712A Corrosion of third degree of left ankle, initial encounter
T25.712D Corrosion of third degree of left ankle, subsequent encounter
T25.712S Corrosion of third degree of left ankle, sequela
T25.721A Corrosion of third degree of right foot, initial encounter
T25.721D Corrosion of third degree of right foot, subsequent encounter
T25.721S Corrosion of third degree of right foot, sequela
T25.722A Corrosion of third degree of left foot, initial encounter
T25.722D Corrosion of third degree of left foot, subsequent encounter
T25.722S Corrosion of third degree of left foot, sequela
T25.731A Corrosion of third degree of right toe(s) (nail), initial encounter
T25.731D Corrosion of third degree of right toe(s) (nail), subsequent encounter
T25.731S Corrosion of third degree of right toe(s) (nail), sequela
T25.732A Corrosion of third degree of left toe(s) (nail), initial encounter
T25.732D Corrosion of third degree of left toe(s) (nail), subsequent encounter
T25.732S Corrosion of third degree of left toe(s) (nail), sequela
T25.791A Corrosion of third degree of multiple sites of right ankle and foot, initial encounter
T25.791D Corrosion of third degree of multiple sites of right ankle and foot, subsequent encounter
T25.791S Corrosion of third degree of multiple sites of right ankle and foot, sequela
T25.792A Corrosion of third degree of multiple sites of left ankle and foot, initial encounter
T25.792D Corrosion of third degree of multiple sites of left ankle and foot, subsequent encounter
T25.792S Corrosion of third degree of multiple sites of left ankle and foot, sequela
T26.21XA Burn with resulting rupture and destruction of right eyeball, initial encounter
T26.21XD Burn with resulting rupture and destruction of right eyeball, subsequent encounter
T26.21XS Burn with resulting rupture and destruction of right eyeball, sequela
T26.22XA Burn with resulting rupture and destruction of left eyeball, initial encounter
T26.22XD Burn with resulting rupture and destruction of left eyeball, subsequent encounter
T26.22XS Burn with resulting rupture and destruction of left eyeball, sequela

Group 2

(66 Codes)
Group 2 Paragraph

Abdominal Lipectomy/Panniculectomy (CPT Codes 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839 and 15847)

Group 2 Codes
Code Description
A31.1 Cutaneous mycobacterial infection
A43.1 Cutaneous nocardiosis
A46 Erysipelas
A48.0 Gas gangrene
B35.6 Tinea cruris
B35.8 Other dermatophytoses
B37.2 Candidiasis of skin and nail
B95.0 Streptococcus, group A, as the cause of diseases classified elsewhere
B95.1 Streptococcus, group B, as the cause of diseases classified elsewhere
B95.2 Enterococcus as the cause of diseases classified elsewhere
B95.3 Streptococcus pneumoniae as the cause of diseases classified elsewhere
B95.4 Other streptococcus as the cause of diseases classified elsewhere
B95.61 Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere
B95.62 Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere
B95.7 Other staphylococcus as the cause of diseases classified elsewhere
B96.0 Mycoplasma pneumoniae [M. pneumoniae] as the cause of diseases classified elsewhere
B96.1 Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere
B96.3 Hemophilus influenzae [H. influenzae] as the cause of diseases classified elsewhere
B96.4 Proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere
B96.5 Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere
B96.6 Bacteroides fragilis [B. fragilis] as the cause of diseases classified elsewhere
B96.7 Clostridium perfringens [C. perfringens] as the cause of diseases classified elsewhere
B96.81 Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere
B96.82 Vibrio vulnificus as the cause of diseases classified elsewhere
B96.83 Acinetobacter baumannii as the cause of diseases classified elsewhere
B96.89 Other specified bacterial agents as the cause of diseases classified elsewhere
I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh
I70.238 Atherosclerosis of native arteries of right leg with ulceration of other part of lower leg
I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh
I70.248 Atherosclerosis of native arteries of left leg with ulceration of other part of lower leg
I70.25 Atherosclerosis of native arteries of other extremities with ulceration
I70.431 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of thigh
I70.441 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of thigh
I70.45 Atherosclerosis of autologous vein bypass graft(s) of other extremity with ulceration
I70.531 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of thigh
I70.541 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of thigh
I70.55 Atherosclerosis of nonautologous biological bypass graft(s) of other extremity with ulceration
I70.631 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of thigh
I70.641 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of thigh
I70.65 Atherosclerosis of nonbiological bypass graft(s) of other extremity with ulceration
I70.731 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of thigh
I70.741 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of thigh
I70.75 Atherosclerosis of other type of bypass graft(s) of other extremity with ulceration
L03.311 Cellulitis of abdominal wall
L08.1 Erythrasma
L30.4 Erythema intertrigo
L97.111 Non-pressure chronic ulcer of right thigh limited to breakdown of skin
L97.112 Non-pressure chronic ulcer of right thigh with fat layer exposed
L97.113 Non-pressure chronic ulcer of right thigh with necrosis of muscle
L97.114 Non-pressure chronic ulcer of right thigh with necrosis of bone
L97.121 Non-pressure chronic ulcer of left thigh limited to breakdown of skin
L97.122 Non-pressure chronic ulcer of left thigh with fat layer exposed
L97.123 Non-pressure chronic ulcer of left thigh with necrosis of muscle
L97.124 Non-pressure chronic ulcer of left thigh with necrosis of bone
L98.411 Non-pressure chronic ulcer of buttock limited to breakdown of skin
L98.412 Non-pressure chronic ulcer of buttock with fat layer exposed
L98.413 Non-pressure chronic ulcer of buttock with necrosis of muscle
L98.414 Non-pressure chronic ulcer of buttock with necrosis of bone
L98.421 Non-pressure chronic ulcer of back limited to breakdown of skin
L98.422 Non-pressure chronic ulcer of back with fat layer exposed
L98.423 Non-pressure chronic ulcer of back with necrosis of muscle
L98.424 Non-pressure chronic ulcer of back with necrosis of bone
L98.491 Non-pressure chronic ulcer of skin of other sites limited to breakdown of skin
L98.492 Non-pressure chronic ulcer of skin of other sites with fat layer exposed
L98.493 Non-pressure chronic ulcer of skin of other sites with necrosis of muscle
L98.494 Non-pressure chronic ulcer of skin of other sites with necrosis of bone

Group 3

(71 Codes)
Group 3 Paragraph

Reconstructive Breast Surgery (CPT Codes 19316, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396)

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
D04.5 Carcinoma in situ of skin of trunk
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
T85.41XD Breakdown (mechanical) of breast prosthesis and implant, subsequent encounter
T85.41XS Breakdown (mechanical) of breast prosthesis and implant, sequela
T85.42XA Displacement of breast prosthesis and implant, initial encounter
T85.42XD Displacement of breast prosthesis and implant, subsequent encounter
T85.42XS Displacement of breast prosthesis and implant, sequela
T85.43XA Leakage of breast prosthesis and implant, initial encounter
T85.43XD Leakage of breast prosthesis and implant, subsequent encounter
T85.43XS Leakage of breast prosthesis and implant, sequela
T85.44XA Capsular contracture of breast implant, initial encounter
T85.44XD Capsular contracture of breast implant, subsequent encounter
T85.44XS Capsular contracture of breast implant, sequela
T85.49XA Other mechanical complication of breast prosthesis and implant, initial encounter
T85.49XD Other mechanical complication of breast prosthesis and implant, subsequent encounter
T85.49XS Other mechanical complication of breast prosthesis and implant, sequela
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
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

(2 Codes)
Group 4 Paragraph

Reduction Mammoplasty (CPT Code 19318)

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

Primary ICD-10-CM:

Group 4 Codes
Code Description
N62* Hypertrophy of breast
N65.1* Disproportion of reconstructed breast
Group 4 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Primary diagnosis N62 must be billed with two of the secondary diagnoses: listed in Group 5 Secondary Codes for Reduction Mammaplasty. When billing for surgery on the unaffected breast to restore symmetry following breast cancer surgery on the contralateral breast, N65.1 must be used as the primary diagnosis with one of the C50.XXX ICD-10 codes as a secondary diagnosis.

C50.XXX Codes:

C50.011
C50.012
C50.021
C50.022
C50.111
C50.112
C50.121
C50.122
C50.211
C50.212
C50.221
C50.222
C50.311
C50.312
C50.321
C50.322
C50.411
C50.412
C50.421
C50.422
C50.511
C50.512
C50.521
C50.522
C50.611
C50.612
C50.621
C50.622
C50.811
C50.812
C50.821
C50.822

 

Group 5

(23 Codes)
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.

Group 5 Codes
Code Description
L26* Exfoliative dermatitis
L30.4* Erythema intertrigo
L53.8* Other specified erythematous conditions
L54* Erythema in diseases classified elsewhere
L92.0* Granuloma annulare
L95.1* Erythema elevatum diutinum
L98.2* Febrile neutrophilic dermatosis [Sweet]
M25.511* Pain in right shoulder
M25.512* Pain in left shoulder
M40.04 Postural kyphosis, thoracic region
M53.81 Other specified dorsopathies, occipito-atlanto-axial region
M53.82 Other specified dorsopathies, cervical region
M53.83 Other specified dorsopathies, cervicothoracic region
M53.84 Other specified dorsopathies, thoracic region
M54.2* Cervicalgia
M54.6* Pain in thoracic spine
M54.89* Other dorsalgia
M54.9* Dorsalgia, unspecified
M95.4 Acquired deformity of chest and rib
N64.4 Mastodynia
R20.2 Paresthesia of skin
R21* Rash and other nonspecific skin eruption
Z85.3* Personal history of malignant neoplasm of breast
Group 5 Medical Necessity ICD-10-CM Codes Asterisk Explanation

N/A

Group 6

(26 Codes)
Group 6 Paragraph

Rhinoplasty (CPT Codes 30400-30450)

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
J34.0 Abscess, furuncle and carbuncle of nose
J34.1 Cyst and mucocele of nose and nasal sinus
J34.89 Other specified disorders of nose and nasal sinuses
S02.2XXA Fracture of nasal bones, initial encounter for closed fracture
S02.2XXB Fracture of nasal bones, initial encounter for open fracture
S02.2XXD Fracture of nasal bones, subsequent encounter for fracture with routine healing
S02.2XXG Fracture of nasal bones, subsequent encounter for fracture with delayed healing
S02.2XXK Fracture of nasal bones, subsequent encounter for fracture with nonunion
S02.2XXS Fracture of nasal bones, sequela
N/A

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

Group 1

Group 1 Paragraph

All ICD-10-CM codes not listed above under ICD-10-CM Codes That Support Medical Necessity above.

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

N/A

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
999x Not Applicable
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
99999 Not Applicable
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
10/01/2023 R6

Updated to indicate this article is an LCD reference Article.

10/01/2023 R5

Per 2023 ICD-10 Annual updates, ICD-10-CM code B96.83 is being added to Group 2.

01/01/2021 R4

Updated Group 4: Medical Necessity ICD-10-CM Codes Asterisk Explanation to say: When billing for surgery on the unaffected breast to restore symmetry following breast cancer surgery on the contralateral breast, N65.1 must be used as the primary diagnosis with one of the C50.XXX ICD-10 codes as a secondary diagnosis.

01/01/2021 R3

Under CPT/HCPCS Codes Group 1:

Descriptor Changes: 19318, 19325, 19328, 19330, 19340, 19342, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380.

This revision is due to the Q1 2021 CPT/HCPCS Code Update and is effective for dates of service on or after 01/01/2021.

01/01/2021 R2

Under CPT/HCPCS Codes Group 1:

Deleted Codes:19324; 19366

Descriptor Changes: 15780; 15781; 15782; 15783; 19316

Under Group III Paragraph of ICD-10 codes that support Medical Necessity: Removed 19324 and 19366

This revision is due to the Q1 2021 CPT/HCPCS Code Update and is effective for dates of service on or after 01/01/2021.

10/01/2019 R1

10/01/2019: Revision done to add CPT codes 15838 and 15839 to Group 2 Paragraph.

N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
N/A
SAD Process URL 1
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SAD Process URL 2
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
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Keywords

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