LCD Reference Article Billing and Coding Article

Billing and Coding: Cosmetic and Reconstructive Surgery

A59299

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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.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A59299
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Cosmetic and Reconstructive Surgery
Article Type
Billing and Coding
Original Effective Date
05/28/2023
Revision Effective Date
11/16/2023
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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 © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (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

CMS PUB. 100-02 Medicare Benefit Policy Manual
Chapter 1 – Inpatient Hospital Services Covered under Part A
§120 - Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare
Chapter 16-General Exclusions from Coverage:
§120 Cosmetic Surgery
§180 - Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare.

CMS PUB. 100-3 Medicare National Coverage Determinations Manual
Chapter 1, Part 2
§140.2 - Breast Reconstruction Following Mastectomy
§140.4 - Plastic Surgery to Correct "Moon Face"
Chapter 1, Part 4
§250.4 – Treatment of Actinic Keratosis
§250.5 - Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS)

CMS PUB 100-04 Medicare Claims Processing Manual
Chapter 32 - Billing Requirements for Special Services
§260 - Dermal Injections for Treatment of Facial Lipodystrophy Syndrome (LDS)

National Coverage Determination 250.5 Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome

Title XVIII of the Social Security Act (SSA): 1862 (a)(1)(A) Medically Reasonable & Necessary tests used in the diagnosis and management of illness or injury or to improve the function of a malformed body part.
Title XVIII of the Social Security Act (SSA): 1862 (a)(1)(D) Investigational or Experimental.
Title XVIII of the Social Security Act, Section 1862 (a)(10). This section excludes Cosmetic Surgery.

Change Request 10901, Transmittal 829, Local Coverage Determinations (LCDs) October 3, 2018

Article Guidance

Article Text

The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD DL39506 Cosmetic and Reconstructive Surgery.

This article will support reconstructive surgery performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease. It is generally performed to improve function but may also be done to approximate a normal appearance.

This article will not support cosmetic surgery performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.

Coding Guidelines

  1. Claims do not have to be submitted for cosmetic procedures. However, if a denial of Medicare coverage is necessary, a GY modifier (items or services statutorily excluded or does not meet the definition of any Medicare benefit) can be used on a cosmetic procedure to receive a non-covered denial. Use diagnosis code: Z41.1 Encounter for cosmetic surgery.
  2. All submitted non-covered or no payment claims using condition code 21 will be processed to completion, and all services on those claims, since they are submitted as non-covered, will be denied. The default liability for payment of these claims is assigned to the beneficiary, who may then submit the denial from Medicare, as the primary payer, to subsequent payer(s) for consideration. Since a denial is a Medicare determination of payment, all services submitted on no payment claims may be appealed later if unusual circumstances so warrant. That is, all payment determinations are subject to appeal, even denials of services submitted as non-covered.

Documentation Requirements
For all procedures:

  1. All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The medical record documentation must support the medical necessity of the services as stated in this policy.

Documentation Requirements for Specific Services

Reconstructive Surgery: Removal of Breast Implants

  • The medical record must describe the condition which supports the removal of a breast implant(s) as medically reasonable and necessary.

Breast Reduction

The beneficiary’s medical record must contain the following information:

  • Height and weight.
  • Body Surface Area (BSA)
  • Clinical evaluation of the signs and/or symptoms ascribed to the macromastia, therapies prior to breast reduction 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 with the weight of the tissue removed from each breast.
  • Documentation of back or neck or shoulder pain from macromastia that was unrelieved by 6 months of conservative analgesia, supportive measures (garment, etc.), and physical therapy.

Mastectomy for gynecomastia

  • Glandular breast tissue confirming true gynecomastia is documented on physical exam and/or mammography
  • Documentation that the gynecomastia persists, despite correction of any underlying causes
  • Documentation supporting that the gynecomastia is classified as Grade III or IV per the American Society of Plastic Surgeons classification
  • Documentation that hormonal causes, including hyperthyroidism, estrogen excess, hyperprolactinemia and hypogonadism have been excluded by appropriate laboratory testing (e.g. with levels of thyroid stimulating hormone [TSH], estradiol, prolactin, testosterone and or luteinizing hormone [LH])
  • Documentation supporting that gynecomastia persists after 6 months of unsuccessful medical treatment, the use of potential gynecomastia-inducing drugs and substances has been ruled out and gynecomastia persist for at least one year. (ASPS)

Tattooing or to correct color defects of the skin must indicate the prior condition i.e. post-mastectomy, trauma necessitating the reconstruction in the progress notes.

Punch graft hair transplants: pre-operative photographs must be made available upon Contractor request.

Rhinoplasty

  • The medical record must include a description of the condition requiring the rhinoplasty.
  • When performed for chronic obstruction the medical record must indicate what is causing the obstruction.
  • Documentation of anterior rhinoscopy, endoscopy, Cottle maneuver/modified Cottle maneuver and/or CT report is recommended to help support medical necessity if requested.
  • The medical record should include a description of any conservative treatment that has been utilized to treat obstruction and the length of time that the conservative treatment has been trialed.
  • Surgical/pathology report if post operative

Septoplasty

  • The medical record must contain the medical and antibiotic therapy that was utilized and the length of time treatment was trialed for recurrent sinusitis secondary to deviated septum.
  • When the procedure is being done for asymptomatic septal deformity to gain access to other transnasal areas during another medically necessary procedure the medical record must indicate what surgical procedure is being performed.
  • The medical record must contain the medical management utilized and the length of time that the treatment was trialed for obstructed nasal breathing due to septal deformity or deviation that is interfering with the effective use of Continuous Positive Airway Pressure (CPAP) for the treatment of an obstructive sleep disorder.

Abdominal Lipectomy/Panniculectomy

The beneficiary’s medical record must contain the following information:

  • the evaluation and management supporting the medical necessity and/or complications with decision to perform surgery,
  • surgical operative record,
  • description of the pannus and the underlying skin,
  • documentation that the panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing),
  • description of conservative treatment undertaken and its results,
  • evidence that the individual has maintained a stable weight for at least 6 months.

Rhytidectomy documentation should include the evaluation and management note in which the decision to perform surgery was made, surgical note and any notes documenting the functional impairment.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(18 Codes)
Group 1 Paragraph

Reconstructive Breast Surgery: Removal of Breast Implants

Group 1 Codes
Code Description
19316 MASTOPEXY
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

Group 2

(1 Code)
Group 2 Paragraph

Reduction Mammaplasty

Group 2 Codes
Code Description
19318 BREAST REDUCTION

Group 3

(1 Code)
Group 3 Paragraph

Mastectomy for Gynecomastia

Group 3 Codes
Code Description
19300 MASTECTOMY FOR GYNECOMASTIA

Group 4

(3 Codes)
Group 4 Paragraph

Tattooing

Group 4 Codes
Code Description
11920 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.0 SQ CM OR LESS
11921 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.1 TO 20.0 SQ CM
11922 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; EACH ADDITIONAL 20.0 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Group 5

(2 Codes)
Group 5 Paragraph

Punch graft

Group 5 Codes
Code Description
15775 PUNCH GRAFT FOR HAIR TRANSPLANT; 1 TO 15 PUNCH GRAFTS
15776 PUNCH GRAFT FOR HAIR TRANSPLANT; MORE THAN 15 PUNCH GRAFTS

Group 6

(9 Codes)
Group 6 Paragraph

Rhinoplasty/Nasal Reconstructive Surgery

Group 6 Codes
Code Description
30400 - 30450 RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES AND/OR ELEVATION OF NASAL TIP - RHINOPLASTY, SECONDARY; MAJOR REVISION (NASAL TIP WORK AND OSTEOTOMIES)
30460 RHINOPLASTY FOR NASAL DEFORMITY SECONDARY TO CONGENITAL CLEFT LIP AND/OR PALATE, INCLUDING COLUMELLAR LENGTHENING; TIP ONLY
30462 RHINOPLASTY FOR NASAL DEFORMITY SECONDARY TO CONGENITAL CLEFT LIP AND/OR PALATE, INCLUDING COLUMELLAR LENGTHENING; TIP, SEPTUM, OSTEOTOMIES
30520 SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT

Group 7

(4 Codes)
Group 7 Paragraph

Chemical Peel

Group 7 Codes
Code Description
15788 - 15793 CHEMICAL PEEL, FACIAL; EPIDERMAL - CHEMICAL PEEL, NONFACIAL; DERMAL

Group 8

(3 Codes)
Group 8 Paragraph

Abdominal Lipectomy/Panniculectomy

Group 8 Codes
Code Description
15830 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY
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)
15877 SUCTION ASSISTED LIPECTOMY; TRUNK

Group 9

(3 Codes)
Group 9 Paragraph

Dermal Filler and Injection

Group 9 Codes
Code Description
G0429 DERMAL FILLER INJECTION(S) FOR THE TREATMENT OF FACIAL LIPODYSTROPHY SYNDROME (LDS) (E.G., AS A RESULT OF HIGHLY ACTIVE ANTIRETROVIRAL THERAPY)
Q2026 INJECTION, RADIESSE, 0.1 ML
Q2028 INJECTION, SCULPTRA, 0.5 MG

Group 10

(2 Codes)
Group 10 Paragraph

The following CPT codes/procedures are generally considered cosmetic and may be medically reviewed or denied as non covered.

Group 10 Codes
Code Description
15828 RHYTIDECTOMY; CHEEK, CHIN, AND NECK
15829 RHYTIDECTOMY; SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM (SMAS) FLAP

Group 11

(26 Codes)
Group 11 Paragraph

The following CPT codes/procedures are considered cosmetic and will be denied as non covered.

Group 11 Codes
Code Description
11950 - 11954 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (EG, COLLAGEN); 1 CC OR LESS - SUBCUTANEOUS INJECTION OF FILLING MATERIAL (EG, COLLAGEN); OVER 10.0 CC
15780 DERMABRASION; TOTAL FACE (EG, FOR ACNE SCARRING, FINE WRINKLING, RHYTIDS, GENERAL KERATOSIS)
15782 DERMABRASION; REGIONAL, OTHER THAN FACE
15783 DERMABRASION; SUPERFICIAL, ANY SITE (EG, TATTOO REMOVAL)
15819 CERVICOPLASTY
15824 - 15826 RHYTIDECTOMY; FOREHEAD - RHYTIDECTOMY; GLABELLAR FROWN LINES
15832 - 15839 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); THIGH - EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA
15876 SUCTION ASSISTED LIPECTOMY; HEAD AND NECK
15878 SUCTION ASSISTED LIPECTOMY; UPPER EXTREMITY
15879 SUCTION ASSISTED LIPECTOMY; LOWER EXTREMITY
17340 CRYOTHERAPY (CO2 SLUSH, LIQUID N2) FOR ACNE
17360 CHEMICAL EXFOLIATION FOR ACNE (EG, ACNE PASTE, ACID)
17380 ELECTROLYSIS EPILATION, EACH 30 MINUTES
69300 OTOPLASTY, PROTRUDING EAR, WITH OR WITHOUT SIZE REDUCTION
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

(108 Codes)
Group 1 Paragraph

The following ICD-10 codes support medical necessity and provider coverage for CPT Codes: 19316, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380 and 19396 for Reconstructive Surgery: Removal of Breast Implants.
For codes in the table below that require a 7th character, letter A initial encounter, D subsequent encounter or S sequela may be used.

Group 1 Codes
Code Description
C44.501 Unspecified malignant neoplasm of skin of breast
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
C50.511 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
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
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
N60.91 Unspecified benign mammary dysplasia of right breast
N60.92 Unspecified benign mammary dysplasia of left breast
N65.0 Deformity of reconstructed breast
N65.1 Disproportion of reconstructed breast
T85.41XA - T85.41XS Breakdown (mechanical) of breast prosthesis and implant, initial encounter - Breakdown (mechanical) of breast prosthesis and implant, sequela
T85.42XA - T85.42XS Displacement of breast prosthesis and implant, initial encounter - Displacement of breast prosthesis and implant, sequela
T85.43XA - T85.43XS Leakage of breast prosthesis and implant, initial encounter - Leakage of breast prosthesis and implant, sequela
T85.44XA - T85.44XS Capsular contracture of breast implant, initial encounter - Capsular contracture of breast implant, sequela
T85.49XA - T85.49XS Other mechanical complication of breast prosthesis and implant, initial encounter - Other mechanical complication of breast prosthesis and implant, sequela
T85.79XA - T85.79XS Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter - Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, sequela
T85.818A Embolism due to other internal prosthetic devices, implants and grafts, initial encounter
T85.828A Fibrosis due to other internal prosthetic devices, implants and grafts, initial encounter
T85.838A Hemorrhage due to other internal prosthetic devices, implants and grafts, initial encounter
T85.848A Pain due to other internal prosthetic devices, implants and grafts, initial encounter
T85.858A Stenosis due to other internal prosthetic devices, implants and grafts, initial encounter
T85.868A Thrombosis due to other internal prosthetic devices, implants and grafts, initial encounter
T85.898A Other specified complication of other internal prosthetic devices, implants and grafts, initial encounter
Z15.01 Genetic susceptibility to malignant neoplasm of breast
Z42.1 Encounter for breast reconstruction following mastectomy
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
Z48.3 Aftercare following surgery for neoplasm
Z80.3 Family history of malignant neoplasm of breast
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 2

(1 Code)
Group 2 Paragraph

Breast Reduction (CPT 19318) and Mastectomy for Gynecomastia (CPT 19300)
Primary Diagnosis:

Group 2 Codes
Code Description
N62* Hypertrophy of breast
Group 2 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Note: When billing CPT 19318 a secondary diagnosis is needed from Group 3.

Group 3

(19 Codes)
Group 3 Paragraph

Breast Reduction (CPT 19318)
The primary diagnosis must be billed with one of the following secondary diagnoses:
Secondary Diagnoses

Group 3 Codes
Code Description
L26 Exfoliative dermatitis
L30.4 Erythema intertrigo
L53.8 Other specified erythematous conditions
L54 Erythema in diseases classified elsewhere
L95.1 Erythema elevatum diutinum
L98.9 Disorder of the skin and subcutaneous tissue, unspecified
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
N64.1 Fat necrosis of breast
N64.81 Ptosis of breast
N65.1 Disproportion of reconstructed breast
O91.211 Nonpurulent mastitis associated with pregnancy, first trimester
O91.212 Nonpurulent mastitis associated with pregnancy, second trimester
O91.213 Nonpurulent mastitis associated with pregnancy, third trimester
R21 Rash and other nonspecific skin eruption
Z48.3* Aftercare following surgery for neoplasm
Group 3 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Note: Use Z48.3 to indicate a mammoplasty to reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery. When reporting Z48.3 it is not necessary to report N62.

Group 4

(3 Codes)
Group 4 Paragraph

Tattooing (CPT 11920, 11921, 11922)

Group 4 Codes
Code Description
L81.8 Other specified disorders of pigmentation
L81.9 Disorder of pigmentation, unspecified
Z42.8 Encounter for other plastic and reconstructive surgery following medical procedure or healed injury

Group 5

(31 Codes)
Group 5 Paragraph

Punch graft hair transplant (CPT 15775-15776)
For codes in the table below that require a 7th character, letter A initial encounter, D subsequent encounter or S sequela may be used.

Group 5 Codes
Code Description
C44.300 Unspecified malignant neoplasm of skin of unspecified part of face
C44.309 Unspecified malignant neoplasm of skin of other parts of face
C44.310 Basal cell carcinoma of skin of unspecified parts of face
C44.319 Basal cell carcinoma of skin of other parts of face
C44.320 Squamous cell carcinoma of skin of unspecified parts of face
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
C44.399 Other specified malignant neoplasm of skin of other parts of face
D04.30 Carcinoma in situ of skin of unspecified part of face
D04.39 Carcinoma in situ of skin of other parts of face
D04.8 Carcinoma in situ of skin of other sites
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
D48.5 Neoplasm of uncertain behavior of skin
S09.10XA Unspecified injury of muscle and tendon of head, initial encounter
S09.11XA Strain of muscle and tendon of head, initial encounter
S09.19XA Other specified injury of muscle and tendon of head, initial encounter
S09.8XXA Other specified injuries of head, initial encounter
T20.06XA - T20.06XS Burn of unspecified degree of forehead and cheek, initial encounter - Burn of unspecified degree of forehead and cheek, sequela
T20.16XA - T20.16XS Burn of first degree of forehead and cheek, initial encounter - Burn of first degree of forehead and cheek, sequela
T20.26XA Burn of second degree of forehead and cheek, initial encounter
T20.36XA Burn of third degree of forehead and cheek, initial encounter
T20.66XA Corrosion of second degree of forehead and cheek, initial encounter
T20.76XA Corrosion of third degree of forehead and cheek, initial encounter
Z48.89* Encounter for other specified surgical aftercare
Group 5 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Note: Use Z48.89 to report punch graft procedures performed for eyebrow replacement due to removal of tumor.

Group 6

(54 Codes)
Group 6 Paragraph

Rhinoplasty/Nasal Reconstruction (CPT codes 30400-30450, 30460, 30462, 30520)
For codes that require a 7th character, letters A,B,D,G,K, or S may be used. Use J34.89 to indicate nasal obstruction.

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
C44.301 Unspecified malignant neoplasm of skin of nose
C44.309 Unspecified malignant neoplasm of skin 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
J32.0 Chronic maxillary sinusitis
J32.1 Chronic frontal sinusitis
J32.2 Chronic ethmoidal sinusitis
J32.3 Chronic sphenoidal sinusitis
J32.4 Chronic pansinusitis
J34.0 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
Q30.0 Choanal atresia
Q30.8 Other congenital malformations of nose
Q35.1 Cleft hard palate
Q35.3 Cleft soft palate
Q35.5 Cleft hard palate with cleft soft palate
Q35.7 Cleft uvula
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
Q67.4 Other congenital deformities of skull, face and jaw
R04.0 Epistaxis
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

(1 Code)
Group 7 Paragraph

Chemical Peel (CPT 15788-15793)

Group 7 Codes
Code Description
L57.0 Actinic keratosis

Group 8

(6 Codes)
Group 8 Paragraph

Abdominal lipectomy/panniculectomy (CPT 15830, 15847, 15877)

Group 8 Codes
Code Description
E65* Localized adiposity
L30.4* Erythema intertrigo
L98.7 Excessive and redundant skin and subcutaneous tissue
M79.3 Panniculitis, unspecified
R26.2* Difficulty in walking, not elsewhere classified
Z74.09* Other reduced mobility
Group 8 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Note: dual diagnosis reporting is required to support the service as medically reasonable and necessary. ICD-10 diagnosis codes L98.7 or M79.3 should be reported as the primary diagnosis with ICD-10 codes E65, L30.4, R26.2, or Z74.09 reported as the secondary diagnosis. 

Group 9

(2 Codes)
Group 9 Paragraph

Dermal Filler injection(s) (G0429), Injection, Radiesse, 0.1ml (Q2026), Injection, Sculptra, 0.1ml (Q2028).
Both diagnoses are required on the claim. Q2026 and Q2028 must be billed with G0429

Group 9 Codes
Code Description
B20 Human immunodeficiency virus [HIV] disease
E88.1 Lipodystrophy, not elsewhere classified

Group 10

Group 10 Paragraph

Rhytidectomy (CPT 15828, 15829)

Group 10 Codes

N/A

N/A

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

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
Z41.1 Encounter for cosmetic surgery
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
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
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
11/16/2023 R2

Revision Effective: 11/16/2023

Revision Explanation: Updated LCD Reference Article section.

05/28/2023 R1

R1

Revision Effective: 05/28/2023

Revision Explanation: Removed N62 from ICD-10 group 3 as it was added in error.

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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
L39506 - 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
N/A
CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
11/08/2023 11/16/2023 - N/A Currently in Effect You are here
05/16/2023 05/28/2023 - 11/15/2023 Superseded View
04/06/2023 05/28/2023 - N/A Superseded View

Keywords

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