Billing and Coding: Cosmetic and Reconstructive Surgery

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L38914, Cosmetic and Reconstructive Surgery.
Please refer to the LCD for reasonable and necessary requirements.

  
**Coding Guidance**  
  
Notice: It is not appropriate to bill Medicare for services that are not
covered (as described by the entire LCD) as if they are covered. When billing
for non-covered services, use the appropriate modifier.  
  
**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 submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.

  
**Documentation Requirements for Specified Services**  
  
 **Dermabrasion**

  1. The medical record must describe the beneficiary's disease process of the rhinophyma that is being treated with dermabrasion.

**Abdominal Lipectomy/Panniculectomy**

  1. The medical record must contain the following information: 
    * Description of the pannus and underlying skin.
    * Documentation that the panniculus causes chronic intertrigo (dermatitis occurring on the opposed surfaces of the skin, skin irritation, infection, or chafing).
    * Description of functional impairments (e.g., difficulty walking, exercising, or impairment in activities of daily living).
    * Description of conservative treatment the beneficiary has received and the results of treatment.
    * Preoperative photographs of the pannus and underlying skin are recommended.

**Reconstructive Breast Surgery: Removal of Breast Implants**

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

**Reduction Mammaplasty**

  1. The beneficiary's medical record must contain the following information: 
    * Height and weight.
    * Clinical evaluation of the signs or symptoms ascribed to the macromastia, therapies prior to reduction mammaplasty and the responses to these therapies.
    * Mammogram report for age appropriate population.
    * The operative report with documentation of the weight of tissue removed from each breast, obtained in the operating room.
    * The pathology report of the tissue removed from each breast.

**Mastectomy for gynecomastia**

  1. Glandular breast tissue confirming true gynecomastia is documented on physical exam and/or mammography.
  2. Documentation that the gynecomastia persists, despite correction of any underlying causes.
  3. Documentation supporting that the gynecomastia is classified as Grade III or IV per the American Society of Plastic Surgeons (ASPS) classification when the procedure is performed in males.
  4. 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])
  5. Documentation supporting that gynecomastia persists after 3 to 4 months of unsuccessful medical treatment, the use of potential gynecomastia-inducing drugs and substances has been ruled out and gynecomastia persists for at least one year.

**Rhinoplasty**

  1. Photographic documentation of the patient's condition is recommended to help support medical necessity if documentation is requested.
  2. The medical record must include a description of the condition requiring the rhinoplasty.
  3. When rhinoplasty is being performed for chronic obstruction, the medical record must indicate what is causing the obstruction.

**Septoplasty**

  1. The medical record must describe the conservative medical management utilized and the length of time that the treatment was trialed for septal deviation causing nasal airway obstruction.
  2. The medical record must contain the medical and antibiotic therapy that was utilized, and the length of the time treatment was trialed for recurrent sinusitis secondary to deviated septum.
  3. 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.