Article - Billing and Coding: Cosmetic and Reconstructive Surgery (A58774)

CMS National Coverage PolicyCMS PUB. 100-02 Medicare Benefit Policy ManualChapter 1  Inpatient Hospital Services Covered under Part A120 - Services Related to and Required as a Result of Services Which Are Not Covered Under MedicareChapter 16-General Exclusions from Coverage:120 Cosmetic Surgery180 - Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare.CMS PUB. 100-3 Medicare National Coverage Determinations ManualChapter 1, Part 2140.2 - Breast Reconstruction Following Mastectomy140.4 - Plastic Surgery to Correct "Moon Face"Chapter 1, Part 4250.4  Treatment of Actinic Keratosis250.5 - Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS)CMS PUB 100-04 Medicare Claims Processing ManualChapter 32 - Billing Requirements for Special Services260 - Dermal Injections for Treatment of Facial Lipodystrophy Syndrome (LDS)National Coverage Determination 250.5 Dermal Injections for the Treatment of Facial Lipodystrophy SyndromeTitle XVIII of the Social Security Act (SSA): 1862 (a)(1)(A) Medically Reasonable & Necessary allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness of injury or to improve the functioning of a malformed body member.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, 2018Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD DL39051 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 GuidelinesClaimsdo nothave 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 RequirementsFor all procedures:All documentation must be maintained in the patients 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 ServicesReconstructive Surgery: Removal of Breast ImplantsThe medical record must describe the condition which supports the removal of a breast implant(s) as medically reasonable and necessary.Breast ReductionThe beneficiarys 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 gynecomastiaGlandular breast tissue confirming true gynecomastia is documented on physical exam and/or mammographyDocumentation that the gynecomastia persists, despite correction of any underlying causesDocumentation supporting that the gynecomastia is classified as Grade III or IV per the American Society of Plastic Surgeons classificationDocumentation 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)Tattooingor 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.RhinoplastyThe 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 operativeSeptoplastyThe 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.Dermabrasion:The medical record must describe the injury, surgery, or disease process that resulted in the defect.Abdominal Lipectomy/PanniculectomyThe beneficiarys 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.Rhytidectomydocumentation 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.