Wiki bilateral mastectomy with prophylactic breast ?

[tng141@aol.com]

Hello! I am wondering if anyone has had the following denial and if so how did you fight it with insurance.

We recently had a patient come in for a bilateral mastectomy. One side had cancer and the other doctors did a prophylactic removal of breast. The CPT code that was used was 19303 with Diagnosis codes C50.912 and Z40.01. A 50 modifier was also used to show that this was a bilateral procedure. The insurance company is denying it stating that the modifier is not correct. They are stating that we only have the left breast cancer so it should be an LT modifier only. I explained to them that the mastectomy was done on both breasts which is why we put the 50 modifier. They are not recognizing ICD-10 code Z40.01. I even sent a dispute with information and research with my Level 1 dispute and it was upheld. Has anyone encountered this? Also did I do the right thing by putting an 50 modifier ? Any help would be greatly appreciated. Thank You!

diagnosis codes, diagnosis coding

 

[csperoni]

No experience with breast surgery, but there are carriers that simply do not recognize -50 and instead want the claim on 2 separate lines for -LT and -RT. If that's the case here, I would try
19303-LT C50.912
19303-RT Z40.01, C50.912
If they won't recognize Z40.01 at all, despite it being a valid ICD10 code, and the primary reason the right breast was removed, I would then try leaving it off.

diagnosis codes, diagnosis coding