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breast prosthesis

  1. #1
    Default breast prosthesis
    Medical Coding Books
    I need some input regarding breast prosthesis and tissue expanders. We do many of these procedures on patients that are past hx of breast ca and post mastectomy and these prosthesis are expensive but I can't get them paid. Some say they are inclusive, some say implants not covered per contract, some say benefits do not cover implant, I could go on.

    We have appealed quoting the federal law and also explaining that they pay the procedure and you can't do a placement of implant without the implant but I'm getting no where.

    And now Medicare has appended an N1 payment indicator which means they aren't going to pay them anymore either even though a previous bulletin stated that they cover them in an ASC. So if they are not a covered benefit for Medicare, can I have the patient sign an ABN and have the patient pay for them?

    We bill these with different codes: L8600, L8699 and C1789.

    Anybody have any suggestions?


  2. #2
    unfortunately we are "stuck" on this one Terri. MCR continuously change their minds and there are so many implants that arent covered anymore that its not worth doing those cases because reimbursement doesnt even begin to cover the implants

  3. #3
    Thank you for your reply.

    It's discouraging as I'm sure you understand.

    What do you think about the federal law? (for Arizona which is the state I'm in it's A.R.S. ยงยง 20-826(H), 20-934(F), 20-1057(I), 20-1342(A)(9), 20-1402(A)(5), 20-1404(G)) Why doesn't that come into play? Since this is a 'federal' law and they are a 'federal' agency, shouldn't they have to follow it? I know it's an old law but I haven't seen anything that has changed that law so it should still be pertainent. Right?

    Any thoughts on this?

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