Article - Billing and Coding: Plastic Surgery (A57222)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A). Allows coverage and payment for only those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act, 1833(e). Prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.Title XVIII of the Social Security Act, 1862(a)(10). Coverage of cosmetic surgery is discussed.Medicare On-Line Manual System, Publication 100-02,Medicare Benefit Policy Manual,Chapter 16, 10, 120, and 180.Medicare On-Line Manual System, Publication 100-03,Medicare National Coverage Determinations Manual,Chapter 1, Part 2, 140.2 and 140.4.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Cosmetic surgery is performed to reshape normal structures of the body, for the purpose of improving the patients appearance and self-esteem. Per IOM 100-02 Chapter 16, cosmetic surgery and expenses incurred in connection with such surgery are not covered. This exclusion does not apply to surgery in connection with the treatment of severe burns, facial repair following auto trauma, or similar surgeries for therapeutic purposes or reconstruction.For Reduction Mammoplasty:1. Physicians should document the severity of the symptoms of breast hypertrophy and impact on health related quality of life as measured by an accepted breast specific questionnaire.The beneficiary's medical record must contain the following information and be made available to any authorized Medicare auditor upon request:Height and weightClinical evaluation of the signs and/or symptoms ascribed to the macromastia, therapies prior to reduction mammoplasty and the responses to these therapies.The operative report with documentation of the weight of tissue removed fromeach breast, obtained in the operating room.The pathology report of the tissue removed fromeach breast.2. Reasons for denial include:Surgery is deemed or later determined to be cosmetic in nature. Breast surgery for uncomplicated macromastia, pendulous breasts, or to correct otherwise uncomplicated nipple inversions will be considered cosmetic and not reasonable and necessaryFailure to clearly document persistent signs and symptoms despite a reasonable trial of conservative therapy for a reasonable length of time.Services submitted without a listed diagnosis (ICD-10-CM) code supporting medical necessityUse of any ICD-10-CM codes not listed in the ICD-10-CM Codes That Support Medical Necessity Section below.For all procedures noted within this policy:The medical record must be made available to Medicare or a Medicare auditor upon request.The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.Services billed with a diagnosis code that is not listed in the ICD-10-CM Codes That Support Medical Necessity section of this policy may be considered at redetermination on a case-by-case basis.When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services may be denied as not reasonable and necessary.When requesting a written redetermination, providers must include all relevant documentation with the request. Failure to include such items will likely result in an unfavorable determination. While not required, high quality photographs may be useful in determining medical necessity and may be submitted when the provider feels it is appropriate to do so.