Reduction Mammaplasty Requires Multiple Dx

Effective Feb. 15, National Government Services (NGS) will no longer process claims for CPT® 19318 Reduction mammaplasty when solely reported with ICD-9-CM diagnosis code 611.1 Hypertrophy of the breast.

NGS, Medicare Part B contractor for Connecticut, Indiana, Kentucky and New York, says in a notice on their website that CPT® 19318 will be reviewed based on the patient’s symptomology. Payment will be limited to claims with other documented physical symptoms supporting medical necessity.

This is in accordance with National Coverage Determination (NCD) Manual, pub. 100-03, chapter 1, section 140.2, which states, “Reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is considered a relatively safe and effective noncosmetic procedure. Accordingly, program payment may be made for breast reconstruction surgery following removal of a breast for any medical reason.”

In other words, to support a claim for 19318, in addition to ICD-9 code 611.1, you must also report the primary diagnosis that led to the mastectomy which caused the hypertrophy.

Reduction mammaplasty for cosmetic reasons remains noncovered as per Medicare Benefit Policy Manual, pub. 100-02, chapter 12, section 120. When a physician performs a reduction mammaplasty for cosmetic reasons, append modifier GY Item or service statutorily excluded or does not meet the definition of any Medicare benefit to CPT® 19318.


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