General Surgery Coding Alert

Question: Our surgeon performed a bilateral mastectomy for a Medicare patient. The right breast had cancer, but the left breast was removed prophylactically. I billed 19307 x 2 with diagnoses codes 174.9 and V50.41. Is there any way to get this claim paid?

New Jersey Subscriber

Answer: Medicare expects you to bill bilateral procedures using modifier 50 (Bilateral procedure), so the problem may be that you billed 19307 x 2 (Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle).

Do this: Bill the service as 19307-50, listing your primary diagnosis as 174.9 (Malignant neoplasm of breast (female) unspecified site) with a secondary diagnosis of V50.41 (Prophylactic breast removal).

Coverage varies: Payers often have very specific requirements for covering prophylactic breast removal, and personal history of breast cancer is a medical necessity indication for many policies. You should examine the patient's medical record and ensure that she meets the coverage requirements.