Wiki Breast reduction on contralateral breast

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ctidwell

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We have a patient who was diagnosed with breast cancer in her right breast and Medicare paid for the right breast reconstruction. Medicare denied 19318-LT, the left breast reduction which was needed to make the breasts symmetrical.
Diagnoses for left breast are: Macromastia & Breast Asymmetry.
I coded the ICD-9 codes as:
1 611.1 HYPERTROPHY OF BREAST
2 612.1 DISPROPORTION RECONSTRUCTED BREAST
3 V10.3 HX OF BREAST MALIGNANCY
She doesn't have the usual macromastia symptoms such as back pain, intertrigo, etc.
Procedure: Left breast reduction with a Weiss inferior pedicle pattern for symmetry.
According to The Women's Health and Cancer Rights Act (WHCRA), the federal law requires health plans to pay for surgery to the other breast to achieve a symmetrical appearance.

Any suggestions on how it should have been coded for Medicare to pay for it?
 
Put the V10.3 as the prime DX. If is an appeal be sure they are aware of the mastectomy date of the opposite side. We do not use the 611.1 DX. They may just want to review the op note to be sure.
 
Thank you, They wouldn't accept the V10.3 as the primary ICD-9 code for 19318, but I will definitely use that as the primary code in the appeal. Thanks!
 
breast reduction for symmetry

I have the LCD's for plastic surgery in Arizona... It states that 611.1 billed with secondary diagnosis V58.42 is to be used to indicate a mammoplasty to reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery.

Sorry for the delay... Hope it is helpful.
 
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