Wiki Billing Cpt 19318 for symmetry

[mccolloughpsc]

I billed Cpt codes 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 it was cosmetic.
They said the only diagnosis payable for 19318 (reduction) is N62 along with a diagnosis from group 5. 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.

 

[erikarose727]

A reduction for symmetry should also be payable with procedure N65.1 which is disproportion of the native breast to the reconstructed breast under LCD policy L35090. That should be the primary diagnosis for any symmetry procedure. The Women's Health and Cancer Rights Act actually prohibits the denial of procedures performed on the native breast in order to achieve symmetry to the reconstructed breast.

 

[billybrandle1964]

you need to have 19316 with cancer dx and 19318 with dx z48.3

 

[acgibson@namccares.com]

**I think this is an issue that AAPC should address**

I have the same issue and have contacted Medicare Part B. The Carrier for AL says the only primary code for 19318 is N62 (Hypertrophy) with secondary required diagnosis - a limit of 15 codes, none of which are cancer. Other MAC's have LCD's that allow coding of Cancer as the Primary. When I talked with Part B they referred me to use codes from Group 3: (Which I do not believe are appropriate codes for an Oncoplastic Breast Reduction)
Group 3 Paragraph
Medicare is establishing the following limited coverage for RECONstructive breast surgery (CPT® codes 19316, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396):

Medicare coverage manual clearly states... Reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is considered a relatively safe and effective non cosmetic procedure. Accordingly, program payment may be made for breast reconstruction surgery following removal of a breast for any medical reason

 

[acgibson@namccares.com]

A reduction for symmetry should also be payable with procedure N65.1 which is disproportion of the native breast to the reconstructed breast under LCD policy L35090. That should be the primary diagnosis for any symmetry procedure. The Women's Health and Cancer Rights Act actually prohibits the denial of procedures performed on the native breast in order to achieve symmetry to the reconstructed breast.

Our Local MAC has a different LCD - Which required dx of N62