Oncology & Hematology Coding Alert

Question: I billed 19318-RT for symmetry with 19361-LT for breast cancer and absence of breast. Medicare denied it, so I appealed. The appeal was unfavorable stating the 19318 was cosmetic. Is there another code we need to be using when the reduction is done for symmetry? It doesn’t seem right that the doctor is not entitled to reimbursement for this.

AAPC Forum Participant

Answer: You are correct in saying Medicare should reimburse you for your provider’s work. Per Local Coverage Determination (LCD) L35090, reducing “the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery” is a “reconstructive procedure … considered medically reasonable and necessary” (www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=35090).

In this situation, assuming supporting documentation is present in the patient’s medical record, you should resubmit the claim with the CPT^® codes you have given: 19361-LT (Breast reconstruction; with latissimus dorsi flap) and 19318-RT (Breast reduction). For medical necessity, you should link the 19361-LT with the appropriate breast cancer code from C50.- (Malignant neoplasm of breast) and the 19318-RT with N65.1 (Disproportion of reconstructed breast) as the Local Coverage Article (LCA) A56587, which is associated with LCD L35090, indicates “N65.1 may be used as a standalone code when billing for surgery on the unaffected breast to restore symmetry following breast cancer surgery on the contralateral breast.” However, be aware of the local coverage documents provided by your specific Medicare Administrative Contractor as some may prefer other codes, such as Z48.3 (Aftercare following surgery for neoplasm).