SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Cosmetic and Reconstructive Surgery

A56658

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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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Source Article ID
N/A
Article ID
A56658
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Cosmetic and Reconstructive Surgery
Article Type
Billing and Coding
Original Effective Date
07/04/2019
Revision Effective Date
10/01/2023
Revision Ending Date
04/14/2024
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, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, §120 Cosmetic Surgery, §140 Dental Services Exclusion and §180 Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 32, §260 Dermal Injections for Treatment of Facial Lipodystrophy Syndrome (FLS), §260.1 Policy, §260.2 Billing Instructions, §260.2.1 Hospital Billing Instructions, §260.2.2 Practitioner Billing Instructions

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) Cosmetic and Reconstructive Surgery L33428.

 

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Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(4 Codes)
Group 1 Paragraph

The CPT®/HCPCS codes included in this article will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT®/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for dermabrasion (CPT®/HCPCS codes 15780, 15781, 15782 and 15783):

Covered for:

Group 1 Codes
Code Description
L71.0 Perioral dermatitis
L71.1 Rhinophyma
L71.8 Other rosacea
L81.8 Other specified disorders of pigmentation

Group 2

(26 Codes)
Group 2 Paragraph

Medicare is establishing the following limited coverage for abdominal lipectomy/panniculectomy (CPT®/HCPCS codes 15830 and 15847):

Covered for:

Group 2 Codes
Code Description
K43.0 Incisional hernia with obstruction, without gangrene
K43.1 Incisional hernia with gangrene
K43.2 Incisional hernia without obstruction or gangrene
K43.3 Parastomal hernia with obstruction, without gangrene
K43.4 Parastomal hernia with gangrene
K43.5 Parastomal hernia without obstruction or gangrene
K43.6 Other and unspecified ventral hernia with obstruction, without gangrene
K43.7 Other and unspecified ventral hernia with gangrene
K43.9 Ventral hernia without obstruction or gangrene
K46.9 Unspecified abdominal hernia without obstruction or gangrene
L57.4 Cutis laxa senilis
L87.9 Transepidermal elimination disorder, unspecified
L90.9 Atrophic disorder of skin, unspecified
L91.9 Hypertrophic disorder of the skin, unspecified
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
L98.419 Non-pressure chronic ulcer of buttock with unspecified severity
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
L98.429 Non-pressure chronic ulcer of back with unspecified severity
M35.6 Relapsing panniculitis [Weber-Christian]
M79.3 Panniculitis, unspecified

Group 3

(111 Codes)
Group 3 Paragraph

Medicare is establishing the following limited coverage for reconstructive breast surgery (CPT® codes 19316, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396):

Covered for:

Group 3 Codes
Code Description
C44.511 Basal cell carcinoma of skin of breast
C44.521 Squamous cell carcinoma of skin of breast
C44.591 Other specified malignant neoplasm of skin of breast
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
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
C79.2 Secondary malignant neoplasm of skin
C79.81 Secondary malignant neoplasm of breast
C84.7A Anaplastic large cell lymphoma, ALK-negative, 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
D05.91 Unspecified type of carcinoma in situ of right breast
D05.92 Unspecified type of carcinoma in situ of left breast
D22.5 Melanocytic nevi of trunk
D23.5 Other benign neoplasm of skin of trunk
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
N60.01 Solitary cyst of right breast
N60.02 Solitary cyst of left breast
N60.11 Diffuse cystic mastopathy of right breast
N60.12 Diffuse cystic mastopathy of left breast
N60.21 Fibroadenosis of right breast
N60.22 Fibroadenosis of left breast
N60.31 Fibrosclerosis of right breast
N60.32 Fibrosclerosis of left breast
N60.41 Mammary duct ectasia of right breast
N60.42 Mammary duct ectasia of left breast
N60.81 Other benign mammary dysplasias of right breast
N60.82 Other benign mammary dysplasias of left breast
N61.1 Abscess of the breast and nipple
N64.1 Fat necrosis of breast
N64.89 Other specified disorders of breast
N65.0 Deformity of reconstructed breast
N65.1 Disproportion of reconstructed breast
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
T21.71XA 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
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
Z44.30 Encounter for fitting and adjustment of external breast prosthesis, unspecified breast
Z44.31 Encounter for fitting and adjustment of external right breast prosthesis
Z44.32 Encounter for fitting and adjustment of external left breast prosthesis
Z45.811 Encounter for adjustment or removal of right breast implant
Z45.812 Encounter for adjustment or removal of left breast implant
Z45.819 Encounter for adjustment or removal of unspecified breast implant
Z48.3 Aftercare following surgery for neoplasm
Z85.3 Personal history of malignant neoplasm of breast
Z90.11 Acquired absence of right breast and nipple
Z90.12 Acquired absence of left breast and nipple
Z90.13 Acquired absence of bilateral breasts and nipples
Z98.82 Breast implant status

Group 4

(1 Code)
Group 4 Paragraph

Medicare is establishing the following dual-diagnosis limited coverage for reduction mammoplasty (CPT® code 19318):

*Primary diagnosis:

Group 4 Codes
Code Description
N62 Hypertrophy of breast

Group 5

(15 Codes)
Group 5 Paragraph

Medicare is establishing the following dual-diagnosis limited coverage for reduction mammoplasty (CPT® code 19318):

Secondary diagnoses:

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
M54.2 Cervicalgia
M54.6 Pain in thoracic spine
M54.89 Other dorsalgia
M54.9 Dorsalgia, unspecified
N65.1 Disproportion of reconstructed breast
R21 Rash and other nonspecific skin eruption

Group 6

(82 Codes)
Group 6 Paragraph

Medicare is establishing the following limited coverage for rhinoplasty (CPT® codes 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462 and 30468):

Group 6 Codes
Code Description
C30.0 Malignant neoplasm of nasal cavity
C41.0 Malignant neoplasm of bones of skull and face
C43.21 Malignant melanoma of right ear and external auricular canal
C43.22 Malignant melanoma of left ear and external auricular canal
C43.30 Malignant melanoma of unspecified part of face
C43.31 Malignant melanoma of nose
C43.39 Malignant melanoma of other parts of face
C44.212 Basal cell carcinoma of skin of right ear and external auricular canal
C44.219 Basal cell carcinoma of skin of left ear and external auricular canal
C44.222 Squamous cell carcinoma of skin of right ear and external auricular canal
C44.229 Squamous cell carcinoma of skin of left ear and external auricular canal
C44.300 Unspecified malignant neoplasm of skin of unspecified part of face
C44.301 Unspecified malignant neoplasm of skin of nose
C44.309 Unspecified malignant neoplasm of skin of other parts of face
C44.310 Basal cell carcinoma of skin of unspecified parts of face
C44.311 Basal cell carcinoma of skin of nose
C44.319 Basal cell carcinoma of skin of other parts of face
C44.320 Squamous cell carcinoma of skin of unspecified parts of face
C44.321 Squamous cell carcinoma of skin of nose
C44.329 Squamous cell carcinoma of skin of other parts of face
C44.390 Other specified malignant neoplasm of skin of unspecified 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
D03.21 Melanoma in situ of right ear and external auricular canal
D03.22 Melanoma in situ of left ear and external auricular canal
D03.30 Melanoma in situ of unspecified part of face
D03.39 Melanoma in situ of other parts of face
D04.21 Carcinoma in situ of skin of right ear and external auricular canal
D04.22 Carcinoma in situ of skin of left ear and external auricular canal
D04.30 Carcinoma in situ of skin of unspecified part 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
D22.30 Melanocytic nevi of unspecified part of face
D22.39 Melanocytic nevi of other parts of face
D23.30 Other benign neoplasm of skin of unspecified part of face
D23.39 Other benign neoplasm of skin of other parts of face
H72.01 Central perforation of tympanic membrane, right ear
H72.02 Central perforation of tympanic membrane, left ear
H72.03 Central perforation of tympanic membrane, bilateral
H72.2X1 Other marginal perforations of tympanic membrane, right ear
H72.2X2 Other marginal perforations of tympanic membrane, left ear
H72.2X3 Other marginal perforations of tympanic membrane, bilateral
J32.0 Chronic maxillary sinusitis
J32.1 Chronic frontal sinusitis
J32.2 Chronic ethmoidal sinusitis
J32.3 Chronic sphenoidal sinusitis
J32.4 Chronic pansinusitis
J32.8 Other chronic sinusitis
J32.9 Chronic sinusitis, unspecified
J34.0 Abscess, furuncle and carbuncle of nose
J34.1 Cyst and mucocele of nose and nasal sinus
J34.2 Deviated nasal septum
J34.89 Other specified disorders of nose and nasal sinuses
J34.9 Unspecified disorder of nose and nasal sinuses
Q35.1 Cleft hard palate
Q35.3 Cleft soft palate
Q35.5 Cleft hard palate with cleft soft palate
Q35.7 Cleft uvula
Q35.9 Cleft palate, unspecified
Q36.0 Cleft lip, bilateral
Q36.1 Cleft lip, median
Q36.9 Cleft lip, unilateral
Q37.0 Cleft hard palate with bilateral cleft lip
Q37.1 Cleft hard palate with unilateral cleft lip
Q37.2 Cleft soft palate with bilateral cleft lip
Q37.3 Cleft soft palate with unilateral cleft lip
Q37.4 Cleft hard and soft palate with bilateral cleft lip
Q37.5 Cleft hard and soft palate with unilateral cleft lip
Q67.0 Congenital facial asymmetry
Q67.1 Congenital compression facies
Q67.2 Dolichocephaly
Q67.3 Plagiocephaly
Q67.4 Other congenital deformities of skull, face and jaw
R09.81 Nasal congestion
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

Group 7

(403 Codes)
Group 7 Paragraph

Medicare is establishing the following limited coverage for facial and maxillofacial procedures (refer to the CPT® codes as listed in the CPT®/HCPCS Group 7: Paragraph). The CPT® codes and following diagnoses limit the use of reconstructive surgeries of the head and neck to the repair of injuries due to trauma or ablative surgery.

Services billed with a diagnosis code that is not listed under ICD-10-CM Codes that Support Medical Necessity of this article will be denied as not covered. Exceptions will be considered on a case-by-case basis.

Group 7 Codes
Code Description
C00.0 Malignant neoplasm of external upper lip
C00.1 Malignant neoplasm of external lower lip
C00.3 Malignant neoplasm of upper lip, inner aspect
C00.4 Malignant neoplasm of lower lip, inner aspect
C00.5 Malignant neoplasm of lip, unspecified, inner aspect
C00.6 Malignant neoplasm of commissure of lip, unspecified
C00.8 Malignant neoplasm of overlapping sites of lip
C01 Malignant neoplasm of base of tongue
C02.0 Malignant neoplasm of dorsal surface of tongue
C02.1 Malignant neoplasm of border of tongue
C02.2 Malignant neoplasm of ventral surface of tongue
C02.8 Malignant neoplasm of overlapping sites of tongue
C03.0 Malignant neoplasm of upper gum
C03.1 Malignant neoplasm of lower gum
C04.0 Malignant neoplasm of anterior floor of mouth
C04.1 Malignant neoplasm of lateral floor of mouth
C04.8 Malignant neoplasm of overlapping sites of floor of mouth
C05.0 Malignant neoplasm of hard palate
C05.1 Malignant neoplasm of soft palate
C05.2 Malignant neoplasm of uvula
C05.8 Malignant neoplasm of overlapping sites of palate
C06.0 Malignant neoplasm of cheek mucosa
C06.1 Malignant neoplasm of vestibule of mouth
C06.2 Malignant neoplasm of retromolar area
C06.80 Malignant neoplasm of overlapping sites of unspecified parts of mouth
C06.89 Malignant neoplasm of overlapping sites of other parts of mouth
C07 Malignant neoplasm of parotid gland
C08.0 Malignant neoplasm of submandibular gland
C08.1 Malignant neoplasm of sublingual gland
C08.9 Malignant neoplasm of major salivary gland, unspecified
C09.0 Malignant neoplasm of tonsillar fossa
C09.1 Malignant neoplasm of tonsillar pillar (anterior) (posterior)
C09.8 Malignant neoplasm of overlapping sites of tonsil
C10.0 Malignant neoplasm of vallecula
C10.1 Malignant neoplasm of anterior surface of epiglottis
C10.2 Malignant neoplasm of lateral wall of oropharynx
C10.3 Malignant neoplasm of posterior wall of oropharynx
C10.4 Malignant neoplasm of branchial cleft
C10.8 Malignant neoplasm of overlapping sites of oropharynx
C11.0 Malignant neoplasm of superior wall of nasopharynx
C11.1 Malignant neoplasm of posterior wall of nasopharynx
C11.2 Malignant neoplasm of lateral wall of nasopharynx
C11.3 Malignant neoplasm of anterior wall of nasopharynx
C11.8 Malignant neoplasm of overlapping sites of nasopharynx
C12 Malignant neoplasm of pyriform sinus
C13.0 Malignant neoplasm of postcricoid region
C13.1 Malignant neoplasm of aryepiglottic fold, hypopharyngeal aspect
C13.2 Malignant neoplasm of posterior wall of hypopharynx
C13.8 Malignant neoplasm of overlapping sites of hypopharynx
C14.0 Malignant neoplasm of pharynx, unspecified
C14.2 Malignant neoplasm of Waldeyer's ring
C14.8 Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx
C30.0 Malignant neoplasm of nasal cavity
C30.1 Malignant neoplasm of middle ear
C31.0 Malignant neoplasm of maxillary sinus
C31.1 Malignant neoplasm of ethmoidal sinus
C31.2 Malignant neoplasm of frontal sinus
C31.3 Malignant neoplasm of sphenoid sinus
C31.8 Malignant neoplasm of overlapping sites of accessory sinuses
C31.9 Malignant neoplasm of accessory sinus, unspecified
C32.0 Malignant neoplasm of glottis
C32.1 Malignant neoplasm of supraglottis
C32.2 Malignant neoplasm of subglottis
C32.3 Malignant neoplasm of laryngeal cartilage
C32.8 Malignant neoplasm of overlapping sites of larynx
C32.9 Malignant neoplasm of larynx, unspecified
C41.0 Malignant neoplasm of bones of skull and face
C41.1 Malignant neoplasm of mandible
C43.0 Malignant melanoma of lip
C43.111 Malignant melanoma of right upper eyelid, including canthus
C43.112 Malignant melanoma of right lower eyelid, including canthus
C43.121 Malignant melanoma of left upper eyelid, including canthus
C43.122 Malignant melanoma of left lower eyelid, including canthus
C43.21 Malignant melanoma of right ear and external auricular canal
C43.22 Malignant melanoma of left ear and external auricular canal
C43.30 Malignant melanoma of unspecified part of face
C43.31 Malignant melanoma of nose
C43.39 Malignant melanoma of other parts of face
C43.4 Malignant melanoma of scalp and neck
C43.8 Malignant melanoma of overlapping sites of skin
C4A.111 Merkel cell carcinoma of right upper eyelid, including canthus
C4A.112 Merkel cell carcinoma of right lower eyelid, including canthus
C4A.121 Merkel cell carcinoma of left upper eyelid, including canthus
C4A.122 Merkel cell carcinoma of left lower eyelid, including canthus
C4A.21 Merkel cell carcinoma of right ear and external auricular canal
C4A.22 Merkel cell carcinoma of left ear and external auricular canal
C44.1021 Unspecified malignant neoplasm of skin of right upper eyelid, including canthus
C44.1022 Unspecified malignant neoplasm of skin of right lower eyelid, including canthus
C44.1091 Unspecified malignant neoplasm of skin of left upper eyelid, including canthus
C44.1092 Unspecified malignant neoplasm of skin of left lower eyelid, including canthus
C44.1121 Basal cell carcinoma of skin of right upper eyelid, including canthus
C44.1122 Basal cell carcinoma of skin of right lower eyelid, including canthus
C44.1191 Basal cell carcinoma of skin of left upper eyelid, including canthus
C44.1192 Basal cell carcinoma of skin of left lower eyelid, including canthus
C44.1221 Squamous cell carcinoma of skin of right upper eyelid, including canthus
C44.1222 Squamous cell carcinoma of skin of right lower eyelid, including canthus
C44.1291 Squamous cell carcinoma of skin of left upper eyelid, including canthus
C44.1292 Squamous cell carcinoma of skin of left lower eyelid, including canthus
C44.1321 Sebaceous cell carcinoma of skin of right upper eyelid, including canthus
C44.1322 Sebaceous cell carcinoma of skin of right lower eyelid, including canthus
C44.1391 Sebaceous cell carcinoma of skin of left upper eyelid, including canthus
C44.1392 Sebaceous cell carcinoma of skin of left lower eyelid, including canthus
C44.1921 Other specified malignant neoplasm of skin of right upper eyelid, including canthus
C44.1922 Other specified malignant neoplasm of skin of right lower eyelid, including canthus
C44.1991 Other specified malignant neoplasm of skin of left upper eyelid, including canthus
C44.1992 Other specified malignant neoplasm of skin of left lower eyelid, including canthus
C44.212 Basal cell carcinoma of skin of right ear and external auricular canal
C44.219 Basal cell carcinoma of skin of left ear and external auricular canal
C44.222 Squamous cell carcinoma of skin of right ear and external auricular canal
C44.229 Squamous cell carcinoma of skin of left ear and external auricular canal
C44.311 Basal cell carcinoma of skin of nose
C44.321 Squamous cell carcinoma of skin of nose
C44.42 Squamous cell carcinoma of skin of scalp and neck
C47.0 Malignant neoplasm of peripheral nerves of head, face and neck
C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck
C69.51 Malignant neoplasm of right lacrimal gland and duct
C69.52 Malignant neoplasm of left lacrimal gland and duct
C69.61 Malignant neoplasm of right orbit
C69.62 Malignant neoplasm of left orbit
C83.11 Mantle cell lymphoma, lymph nodes of head, face, and neck
C83.31 Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck
C83.81 Other non-follicular lymphoma, lymph nodes of head, face, and neck
C84.41 Peripheral T-cell lymphoma, not elsewhere classified, lymph nodes of head, face, and neck
C84.61 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of head, face, and neck
C84.71 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of head, face, and neck
C85.21 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of head, face, and neck
D03.0 Melanoma in situ of lip
D03.111 Melanoma in situ of right upper eyelid, including canthus
D03.112 Melanoma in situ of right lower eyelid, including canthus
D03.121 Melanoma in situ of left upper eyelid, including canthus
D03.122 Melanoma in situ of left lower eyelid, including canthus
D03.21 Melanoma in situ of right ear and external auricular canal
D03.22 Melanoma in situ of left ear and external auricular canal
D03.30 Melanoma in situ of unspecified part of face
D03.39 Melanoma in situ of other parts of face
D03.4 Melanoma in situ of scalp and neck
D03.8 Melanoma in situ of other sites
D04.111 Carcinoma in situ of skin of right upper eyelid, including canthus
D04.112 Carcinoma in situ of skin of right lower eyelid, including canthus
D04.121 Carcinoma in situ of skin of left upper eyelid, including canthus
D04.122 Carcinoma in situ of skin of left lower eyelid, including canthus
D04.21 Carcinoma in situ of skin of right ear and external auricular canal
D04.22 Carcinoma in situ of skin of left ear and external auricular canal
D09.21 Carcinoma in situ of right eye
D09.22 Carcinoma in situ of left eye
D10.1 Benign neoplasm of tongue
D10.2 Benign neoplasm of floor of mouth
D10.39 Benign neoplasm of other parts of mouth
D10.4 Benign neoplasm of tonsil
D10.5 Benign neoplasm of other parts of oropharynx
D10.6 Benign neoplasm of nasopharynx
D10.7 Benign neoplasm of hypopharynx
D11.0 Benign neoplasm of parotid gland
D11.7 Benign neoplasm of other major salivary glands
D11.9 Benign neoplasm of major salivary gland, unspecified
D14.0 Benign neoplasm of middle ear, nasal cavity and accessory sinuses
D22.0 Melanocytic nevi of lip
D23.0 Other benign neoplasm of skin of lip
D23.111 Other benign neoplasm of skin of right upper eyelid, including canthus
D23.112 Other benign neoplasm of skin of right lower eyelid, including canthus
D23.121 Other benign neoplasm of skin of left upper eyelid, including canthus
D23.122 Other benign neoplasm of skin of left lower eyelid, including canthus
D31.61 Benign neoplasm of unspecified site of right orbit
D31.62 Benign neoplasm of unspecified site of left orbit
D43.3 Neoplasm of uncertain behavior of cranial nerves
D43.8 Neoplasm of uncertain behavior of other specified parts of central nervous system
H05.021 Osteomyelitis of right orbit
H05.022 Osteomyelitis of left orbit
H05.023 Osteomyelitis of bilateral orbits
H05.30 Unspecified deformity of orbit
H05.51 Retained (old) foreign body following penetrating wound of right orbit
H05.52 Retained (old) foreign body following penetrating wound of left orbit
H05.53 Retained (old) foreign body following penetrating wound of bilateral orbits
H05.89 Other disorders of orbit
H44.89 Other disorders of globe
H72.01 Central perforation of tympanic membrane, right ear
H72.02 Central perforation of tympanic membrane, left ear
H72.03 Central perforation of tympanic membrane, bilateral
H72.2X1 Other marginal perforations of tympanic membrane, right ear
H72.2X2 Other marginal perforations of tympanic membrane, left ear
H72.2X3 Other marginal perforations of tympanic membrane, bilateral
J95.01 Hemorrhage from tracheostomy stoma
J95.03 Malfunction of tracheostomy stoma
J95.04 Tracheo-esophageal fistula following tracheostomy
J95.09 Other tracheostomy complication
K09.0 Developmental odontogenic cysts
K09.1 Developmental (nonodontogenic) cysts of oral region
M27.0 Developmental disorders of jaws
M27.1 Giant cell granuloma, central
M27.2 Inflammatory conditions of jaws
M27.3 Alveolitis of jaws
M27.40 Unspecified cyst of jaw
M27.49 Other cysts of jaw
M27.8 Other specified diseases of jaws
M30.1 Polyarteritis with lung involvement [Churg-Strauss]
M31.2 Lethal midline granuloma
M31.30 Wegener's granulomatosis without renal involvement
M31.31 Wegener's granulomatosis with renal involvement
M87.180 Osteonecrosis due to drugs, jaw
Q17.3 Other misshapen ear
Q17.4 Misplaced ear
Q85.00 Neurofibromatosis, unspecified
Q85.01 Neurofibromatosis, type 1
Q85.02 Neurofibromatosis, type 2
Q85.03 Schwannomatosis
Q85.09 Other neurofibromatosis
R13.0 Aphagia
R13.10 Dysphagia, unspecified
R13.11 Dysphagia, oral phase
R13.12 Dysphagia, oropharyngeal phase
S01.05XD Open bite of scalp, subsequent encounter
S01.05XS Open bite of scalp, sequela
S01.111D Laceration without foreign body of right eyelid and periocular area, subsequent encounter
S01.111S Laceration without foreign body of right eyelid and periocular area, sequela
S01.112D Laceration without foreign body of left eyelid and periocular area, subsequent encounter
S01.112S Laceration without foreign body of left eyelid and periocular area, sequela
S01.121D Laceration with foreign body of right eyelid and periocular area, subsequent encounter
S01.121S Laceration with foreign body of right eyelid and periocular area, sequela
S01.122D Laceration with foreign body of left eyelid and periocular area, subsequent encounter
S01.122S Laceration with foreign body of left eyelid and periocular area, sequela
S01.131D Puncture wound without foreign body of right eyelid and periocular area, subsequent encounter
S01.131S Puncture wound without foreign body of right eyelid and periocular area, sequela
S01.132D Puncture wound without foreign body of left eyelid and periocular area, subsequent encounter
S01.132S Puncture wound without foreign body of left eyelid and periocular area, sequela
S01.141D Puncture wound with foreign body of right eyelid and periocular area, subsequent encounter
S01.141S Puncture wound with foreign body of right eyelid and periocular area, sequela
S01.142D Puncture wound with foreign body of left eyelid and periocular area, subsequent encounter
S01.142S Puncture wound with foreign body of left eyelid and periocular area, sequela
S01.151D Open bite of right eyelid and periocular area, subsequent encounter
S01.151S Open bite of right eyelid and periocular area, sequela
S01.152D Open bite of left eyelid and periocular area, subsequent encounter
S01.152S Open bite of left eyelid and periocular area, sequela
S01.20XD Unspecified open wound of nose, subsequent encounter
S01.20XS Unspecified open wound of nose, sequela
S01.21XD Laceration without foreign body of nose, subsequent encounter
S01.21XS Laceration without foreign body of nose, sequela
S01.22XD Laceration with foreign body of nose, subsequent encounter
S01.22XS Laceration with foreign body of nose, sequela
S01.23XD Puncture wound without foreign body of nose, subsequent encounter
S01.23XS Puncture wound without foreign body of nose, sequela
S01.24XD Puncture wound with foreign body of nose, subsequent encounter
S01.24XS Puncture wound with foreign body of nose, sequela
S01.25XD Open bite of nose, subsequent encounter
S01.25XS Open bite of nose, sequela
S01.301D Unspecified open wound of right ear, subsequent encounter
S01.301S Unspecified open wound of right ear, sequela
S01.302D Unspecified open wound of left ear, subsequent encounter
S01.302S Unspecified open wound of left ear, sequela
S01.311D Laceration without foreign body of right ear, subsequent encounter
S01.311S Laceration without foreign body of right ear, sequela
S01.312D Laceration without foreign body of left ear, subsequent encounter
S01.312S Laceration without foreign body of left ear, sequela
S01.319D Laceration without foreign body of unspecified ear, subsequent encounter
S01.319S Laceration without foreign body of unspecified ear, sequela
S01.321D Laceration with foreign body of right ear, subsequent encounter
S01.321S Laceration with foreign body of right ear, sequela
S01.322D Laceration with foreign body of left ear, subsequent encounter
S01.322S Laceration with foreign body of left ear, sequela
S01.329D Laceration with foreign body of unspecified ear, subsequent encounter
S01.329S Laceration with foreign body of unspecified ear, sequela
S01.331D Puncture wound without foreign body of right ear, subsequent encounter
S01.331S Puncture wound without foreign body of right ear, sequela
S01.332D Puncture wound without foreign body of left ear, subsequent encounter
S01.332S Puncture wound without foreign body of left ear, sequela
S01.341D Puncture wound with foreign body of right ear, subsequent encounter
S01.341S Puncture wound with foreign body of right ear, sequela
S01.342D Puncture wound with foreign body of left ear, subsequent encounter
S01.342S Puncture wound with foreign body of left ear, sequela
S01.349D Puncture wound with foreign body of unspecified ear, subsequent encounter
S01.349S Puncture wound with foreign body of unspecified ear, sequela
S01.351D Open bite of right ear, subsequent encounter
S01.351S Open bite of right ear, sequela
S01.352D Open bite of left ear, subsequent encounter
S01.352S Open bite of left ear, sequela
S01.401D Unspecified open wound of right cheek and temporomandibular area, subsequent encounter
S01.401S Unspecified open wound of right cheek and temporomandibular area, sequela
S01.402D Unspecified open wound of left cheek and temporomandibular area, subsequent encounter
S01.402S Unspecified open wound of left cheek and temporomandibular area, sequela
S01.411D Laceration without foreign body of right cheek and temporomandibular area, subsequent encounter
S01.411S Laceration without foreign body of right cheek and temporomandibular area, sequela
S01.412D Laceration without foreign body of left cheek and temporomandibular area, subsequent encounter
S01.412S Laceration without foreign body of left cheek and temporomandibular area, sequela
S01.421D Laceration with foreign body of right cheek and temporomandibular area, subsequent encounter
S01.421S Laceration with foreign body of right cheek and temporomandibular area, sequela
S01.422D Laceration with foreign body of left cheek and temporomandibular area, subsequent encounter
S01.422S Laceration with foreign body of left cheek and temporomandibular area, sequela
S01.429D Laceration with foreign body of unspecified cheek and temporomandibular area, subsequent encounter
S01.429S Laceration with foreign body of unspecified cheek and temporomandibular area, sequela
S01.431D Puncture wound without foreign body of right cheek and temporomandibular area, subsequent encounter
S01.431S Puncture wound without foreign body of right cheek and temporomandibular area, sequela
S01.432D Puncture wound without foreign body of left cheek and temporomandibular area, subsequent encounter
S01.432S Puncture wound without foreign body of left cheek and temporomandibular area, sequela
S01.439D Puncture wound without foreign body of unspecified cheek and temporomandibular area, subsequent encounter
S01.439S Puncture wound without foreign body of unspecified cheek and temporomandibular area, sequela
S01.441D Puncture wound with foreign body of right cheek and temporomandibular area, subsequent encounter
S01.441S Puncture wound with foreign body of right cheek and temporomandibular area, sequela
S01.442D Puncture wound with foreign body of left cheek and temporomandibular area, subsequent encounter
S01.442S Puncture wound with foreign body of left cheek and temporomandibular area, sequela
S01.451D Open bite of right cheek and temporomandibular area, subsequent encounter
S01.451S Open bite of right cheek and temporomandibular area, sequela
S01.452D Open bite of left cheek and temporomandibular area, subsequent encounter
S01.452S Open bite of left cheek and temporomandibular area, sequela
S01.501D Unspecified open wound of lip, subsequent encounter
S01.501S Unspecified open wound of lip, sequela
S01.502D Unspecified open wound of oral cavity, subsequent encounter
S01.502S Unspecified open wound of oral cavity, sequela
S01.511D Laceration without foreign body of lip, subsequent encounter
S01.511S Laceration without foreign body of lip, sequela
S01.512D Laceration without foreign body of oral cavity, subsequent encounter
S01.512S Laceration without foreign body of oral cavity, sequela
S01.521D Laceration with foreign body of lip, subsequent encounter
S01.521S Laceration with foreign body of lip, sequela
S01.522D Laceration with foreign body of oral cavity, subsequent encounter
S01.522S Laceration with foreign body of oral cavity, sequela
S01.531D Puncture wound without foreign body of lip, subsequent encounter
S01.531S Puncture wound without foreign body of lip, sequela
S01.532D Puncture wound without foreign body of oral cavity, subsequent encounter
S01.532S Puncture wound without foreign body of oral cavity, sequela
S01.541D Puncture wound with foreign body of lip, subsequent encounter
S01.541S Puncture wound with foreign body of lip, sequela
S01.542D Puncture wound with foreign body of oral cavity, subsequent encounter
S01.542S Puncture wound with foreign body of oral cavity, sequela
S01.551D Open bite of lip, subsequent encounter
S01.551S Open bite of lip, sequela
S01.552D Open bite of oral cavity, subsequent encounter
S01.552S Open bite of oral cavity, sequela
S01.80XD Unspecified open wound of other part of head, subsequent encounter
S01.80XS Unspecified open wound of other part of head, sequela
S01.81XD Laceration without foreign body of other part of head, subsequent encounter
S01.81XS Laceration without foreign body of other part of head, sequela
S01.82XD Laceration with foreign body of other part of head, subsequent encounter
S01.82XS Laceration with foreign body of other part of head, sequela
S01.83XD Puncture wound without foreign body of other part of head, subsequent encounter
S01.83XS Puncture wound without foreign body of other part of head, sequela
S01.84XD Puncture wound with foreign body of other part of head, subsequent encounter
S01.84XS Puncture wound with foreign body of other part of head, sequela
S01.85XD Open bite of other part of head, subsequent encounter
S01.85XS Open bite of other part of head, sequela
S02.5XXD Fracture of tooth (traumatic), subsequent encounter for fracture with routine healing
S02.5XXG Fracture of tooth (traumatic), subsequent encounter for fracture with delayed healing
S02.5XXK Fracture of tooth (traumatic), subsequent encounter for fracture with nonunion
S02.5XXS Fracture of tooth (traumatic), sequela
S03.2XXD Dislocation of tooth, subsequent encounter
S03.2XXS Dislocation of tooth, sequela
S05.20XD Ocular laceration and rupture with prolapse or loss of intraocular tissue, unspecified eye, subsequent encounter
S05.20XS Ocular laceration and rupture with prolapse or loss of intraocular tissue, unspecified eye, sequela
S05.21XD Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye, subsequent encounter
S05.21XS Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye, sequela
S05.22XD Ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye, subsequent encounter
S05.22XS Ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye, sequela
S05.31XD Ocular laceration without prolapse or loss of intraocular tissue, right eye, subsequent encounter
S05.31XS Ocular laceration without prolapse or loss of intraocular tissue, right eye, sequela
S05.32XD Ocular laceration without prolapse or loss of intraocular tissue, left eye, subsequent encounter
S05.32XS Ocular laceration without prolapse or loss of intraocular tissue, left eye, sequela
S05.41XD Penetrating wound of orbit with or without foreign body, right eye, subsequent encounter
S05.41XS Penetrating wound of orbit with or without foreign body, right eye, sequela
S05.42XD Penetrating wound of orbit with or without foreign body, left eye, subsequent encounter
S05.42XS Penetrating wound of orbit with or without foreign body, left eye, sequela
S05.51XD Penetrating wound with foreign body of right eyeball, subsequent encounter
S05.51XS Penetrating wound with foreign body of right eyeball, sequela
S05.52XD Penetrating wound with foreign body of left eyeball, subsequent encounter
S05.52XS Penetrating wound with foreign body of left eyeball, sequela
S05.61XD Penetrating wound without foreign body of right eyeball, subsequent encounter
S05.61XS Penetrating wound without foreign body of right eyeball, sequela
S05.62XD Penetrating wound without foreign body of left eyeball, subsequent encounter
S05.62XS Penetrating wound without foreign body of left eyeball, sequela
S05.71XD Avulsion of right eye, subsequent encounter
S05.71XS Avulsion of right eye, sequela
S05.72XD Avulsion of left eye, subsequent encounter
S05.72XS Avulsion of left eye, sequela
S05.8X1D Other injuries of right eye and orbit, subsequent encounter
S05.8X1S Other injuries of right eye and orbit, sequela
S05.8X2D Other injuries of left eye and orbit, subsequent encounter
S05.8X2S Other injuries of left eye and orbit, sequela
S05.91XD Unspecified injury of right eye and orbit, subsequent encounter
S05.91XS Unspecified injury of right eye and orbit, sequela
S05.92XD Unspecified injury of left eye and orbit, subsequent encounter
S05.92XS Unspecified injury of left eye and orbit, sequela
S08.111D Complete traumatic amputation of right ear, subsequent encounter
S08.111S Complete traumatic amputation of right ear, sequela
S08.112D Complete traumatic amputation of left ear, subsequent encounter
S08.112S Complete traumatic amputation of left ear, sequela
S08.121D Partial traumatic amputation of right ear, subsequent encounter
S08.121S Partial traumatic amputation of right ear, sequela
S08.122D Partial traumatic amputation of left ear, subsequent encounter
S08.122S Partial traumatic amputation of left ear, sequela
S08.811D Complete traumatic amputation of nose, subsequent encounter
S08.811S Complete traumatic amputation of nose, sequela
S08.812D Partial traumatic amputation of nose, subsequent encounter
S08.812S Partial traumatic amputation of nose, sequela
S08.89XD Traumatic amputation of other parts of head, subsequent encounter
S08.89XS Traumatic amputation of other parts of head, sequela
S09.12XD Laceration of muscle and tendon of head, subsequent encounter
S09.12XS Laceration of muscle and tendon of head, sequela
S09.311D Primary blast injury of right ear, subsequent encounter
S09.311S Primary blast injury of right ear, sequela
S09.312D Primary blast injury of left ear, subsequent encounter
S09.312S Primary blast injury of left ear, sequela
S09.313D Primary blast injury of ear, bilateral, subsequent encounter
S09.313S Primary blast injury of ear, bilateral, sequela
S09.8XXD Other specified injuries of head, subsequent encounter
S09.8XXS Other specified injuries of head, sequela
Z48.1 Encounter for planned postprocedural wound closure
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(6 Codes)
Group 1 Paragraph

The following ICD-10-CM codes are non-covered when billed with any CPT®/HCPCS or ICD-10-PCS codes, not just those included in this article.

Group 1 Codes
Code Description
Z40.8 Encounter for other prophylactic surgery
Z40.9 Encounter for prophylactic surgery, unspecified
Z41.1 Encounter for cosmetic surgery
Z41.3 Encounter for ear piercing
Z41.8 Encounter for other procedures for purposes other than remedying health state
Z41.9 Encounter for procedure for purposes other than remedying health state, unspecified
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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

N/A

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Additional ICD-10 Information

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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

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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

Please accept the License to see the codes.

N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

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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 R12

Under ICD-10 Codes that Support Medical Necessity Group 3: Codes added C44.511, C44.521, C44.591, D22.5, D23.5, N60.01, N60.02, N60.11, N60.12, N60.21, N60.22, N60.31, N60.32, N60.41, N60.42, N60.81, N60.82, N64.1, T21.31XA, T21.31XD, T21.31XS, T21.71XA, T21.71XD, T21.71XS, T85.79XA, T85.79XD and T85.79XS. Formatting was corrected throughout the article.

01/01/2023 R11

Under CPT/HCPCS Codes Group 7: Codes the description was revised for 21089 and 21299. This revision is due to the 2023 Annual/Q1 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/23.

10/01/2022 R10

Under ICD-10 Codes that Support Medical Necessity Group 7: Codes descriptor was revised for C84.41. This revision is due to the Annual ICD-10-CM Update and will become effective on 10/1/22.

06/01/2022 R9

Under ICD-10 Codes that Support Medical Necessity Group 7: Codes added C4A.21 and C4A.22.

10/01/2021 R8

Under ICD-10 Codes that Support Medical Necessity Group 3: Paragraph deleted 19324 and 19366. These codes were deleted along with the Q1 2021 CPT/HCPCS Code Update under revision 6. This revision is retroactive effective for dates of service on or after 1/1/21.

Under ICD-10 Codes that Support Medical Necessity Group 3: Codes added C84.7A. This revision is due to the Annual ICD-10 Update and will become effective on 10/1/21.

07/29/2021 R7

Under CPT/HCPCS Codes Group 7: Paragraph added verbiage “Use CPT® codes only when the physician actually designs and prepares the prosthesis and not when the prosthesis is prepared by an outside laboratory. When CPT® codes 21089 and 21299 are billed, documentation must be submitted with the claim.”. Under ICD-10-CM Codes that Support Medical Necessity Group 1: Paragraph revised verbiage in first sentence to read “The CPT/HCPCS codes included in this article will be subjected to “procedure to diagnosis” editing.”. Under ICD-10-CM Codes that Support Medical Necessity Group 7: Paragraph added verbiage “Services billed with a diagnosis code that is not listed under ICD-10-CM Codes That Support Medical Necessity of this article will be denied as not covered. Exceptions will be considered on a case-by-case basis.”. Under ICD-10-CM Codes that DO NOT Support Medical Necessity Group 1: Paragraph revised verbiage to read “The following ICD-10 codes are non-covered when billed with any CPT/HCPCS or ICD-10 procedure code, not just those included in this article.”. CPT® was inserted throughout the article where applicable. Formatting was corrected throughout the article.

01/01/2021 R6

Under CMS National Coverage Policy added regulation descriptions and updated regulation headings. Under CPT/HCPCS Codes Group 7: Paragraph revised verbiage to read “Facial and Maxillofacial Procedures”. Under ICD-10 Codes that Support Medical Necessity Group 6: Paragraph added 30468 to CPT code verbiage. Under ICD-10 Codes that Support Medical Necessity Group 7: Paragraph revised verbiage in first sentence to read “Medicare is establishing the following limited coverage for facial and maxillofacial procedures (refer to the CPT codes as listed in the CPT/HCPCS Group 7: Paragraph).” Under ICD-10 Codes that Support Medical Necessity Group 7: Codes added C44.42 and Z48.1. CPT® was inserted throughout the article where applicable. This revision is retroactive effective for dates of service on or after 1/1/21.

Under CPT/HCPCS Codes Group 3: Codes deleted 19324 and 19366 and descriptors were changed for 19325, 19328, 19330, 19340, 19342, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371 and 19380. Under CPT/HCPCS Codes Group 4: Codes and Group 5: Codes descriptor was changed for 19318. Under CPT/HCPCS Codes Group 6: Codes and Group 7: Codes added 30468. This revision is due to the Q1 2021 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/2021.

05/19/2020 R5

Under ICD-10 Codes that Support Medical Necessity Group 6: Paragraph deleted 21235. This revision is retroactive effective for dates of service on or after 5/19/20.

05/19/2020 R4

Under CPT/HCPCS Codes Group 7: Codes deleted 21235. Under ICD-10 Codes that Support Medical Necessity Group 2: Codes added L57.4. This revision is retroactive effective for dates of service on or after 5/19/20.

05/19/2020 R3

Under CPT/HCPCS Codes Group 6: Codes deleted 21235. This revision is retroactive effective for dates of service on or after 5/19/20.

10/24/2019 R2

This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of the related Cosmetic and Reconstructive Surgery L33428 LCD and placed in this article.

07/04/2019 R1

All coding located in the Coding Information section has been removed from the related Cosmetic and Reconstructive Surgery L33428 LCD and added to this article.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L33428 - Cosmetic and Reconstructive Surgery
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
08/12/2024 10/01/2024 - N/A Currently in Effect View
06/13/2024 07/01/2024 - 09/30/2024 Superseded View
05/30/2024 07/01/2024 - N/A Superseded View
03/18/2024 04/15/2024 - 06/30/2024 Superseded View
08/29/2023 10/01/2023 - 04/14/2024 Superseded You are here
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Keywords

  • Cosmetic
  • Reconstructive