Medicare coverage for implant removal

Jensina

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I understand that Medicare pays for breast implant removal/replacement when there is a history of breast cancer. I have a pt who had a large lump removed by the Army in 1964 that turned out to be a benign cyst, and she had an implant put in to replace the lost tissue. It wasn't technically a mastectomy, and there's no documented hx of breast CA. The implant is now ruptured and my surgeon will perform a 19371 (periprosthetic capsulectomy) to remove the implant material. Since Medicare doesn't give prior authorizations, is there any possibility that this procedure will be covered? I've had the same procedure denied for a pt who had a mastectomy due to fibrocystic disease, so I'm trying to be pro-active here. I've scoured the MC website and can't find any definite dx criteria for this code, and the Women's Health and Cancer Rights Act of 1998 only guarantees post-mastectomy procedures, with no mention of mandatory CA hx.

Thanks for any help you can provide!
Jensina
 

elenax

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Unfortunately, is not cancer related, Medicare won't cover. Is going to be a self-pay service.:(
 

lkoch829

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What state are you in? Here in Montana, they will pay to have an implant removed (even if its not cancer related) if it is defective. We use ICD-9 996.54 for mechanical implant complication. They also consider V43.82 a payable diagnosis according to the LCD for plastic surgery (Noridian is our carrier).

It seems like they should consider your situation medically necessary. That lump back in 1964 very well could have been cancer so they should cover reconstruction regardless of the pathology outcome. Just make sure to have the patient sign an ABN! If they deny it, appeal it as far as it will go, there has to be at least one reasonable person in Medicare and I don't think a reasonable person would deny your justification for surgery. We did that, it took almost a year but they finally paid it, and they amended the LCD. I wouldn't just take it lying down, due only to the fact it wasn't cancer related. Awesome job being proactive about it!
 

Susan

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19371

Jensina;

Here in Arizona they do pay for the 19371 with diagnosis of 996.54. I also add the code for acquired deformity of the breast as a secondary code to let the payer know. What Medicare will not pay for is the replacement of the implant. I have not had any problems with any carriers not paying for the removal of the implant including our State Medicaid program with the dx of 996.54.

Good Luck!
 

elenax

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Thank you for the feedback! I code for an ASC in Florida and the majority of our cases are self-pay, but if I come across a medicare case I am going to try billing those codes you provided.
 

codegirl0422

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In Alabama they will pay with dx 996.54. We always have them sign an ABN prior just in case.

Just a reminder there is a new ABN as of 3/3/08
"Beginning Monday, March 3, 2008, providers (including independent laboratories), physicians, practitioners, and suppliers may use the revised ABN for all situations where Medicare payment is expected to be denied. The revised ABN replaces the existing ABN-G (Form CMS-R-131G), ABN-L (Form CMS-R-131L), and NEMB (Form CMS-20007). CMS will allow a 6-month transition period from the date of implementation for use of the revised form and instructions. Thus, all providers and suppliers must begin using the revised ABN (CMS-R-131) no later than September 1, 2008." Link listed below to CMS' website.
http://www.cms.hhs.gov/BNI/02_ABNGABNL.asp
 

terridiaz

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We actually had a case a few years ago that a patient had implants for cosmetic reasons and insisted that we bill Medicare for the removal and replace, so I had her sign an ABN and pay upfront for the procedure, know that they wouldn't pay....Well sure enough they came back and paid it all! I took the claim and EOB to the next Medicare meeting that I went to and our rep couldn't believe that they paid on it!!!!! So you never know!
 
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