Billing and Coding: Cosmetic and Reconstructive Surgery

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 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. 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: All documentation must be maintained in the patient’s medical record and made available to the contractor upon request. 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. 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.