15780
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
8.51
Facility
$564.14
Non-Facility
$828.01
Documentation Required
- For Reduction Mammoplasty: Physicians should document the severity of the symptoms of breast hypertrophy and impact on health related quality of life as measured by an accepted breast specific questionnaire.
- For Reduction Mammoplasty: The beneficiary's medical record must contain the following information and be made available to any authorized Medicare auditor upon request: Height and weight.
- For Reduction Mammoplasty: The beneficiary's medical record must contain the following information and be made available to any authorized Medicare auditor upon request: Clinical evaluation of the signs and/or symptoms ascribed to the macromastia, therapies prior to reduction mammoplasty and the responses to these therapies.
- For Reduction Mammoplasty: The beneficiary's medical record must contain the following information and be made available to any authorized Medicare auditor upon request: The operative report with documentation of the weight of tissue removed from each breast, obtained in the operating room.
Key Coverage Criteria
- ICD-10-CM Codes that Support Medical Necessity — Dermabrasion (CPT Codes 15780-15783): L71.0; L71.1; L71.8; T20.311A; T20.311D; T20.311S; T20.312A; T20.312D; T20.312S; T20.32XA; T20.32XD; T20.32XS; T20.33XA; T20.33XD; T20.33XS; T20.34XA; T20.34XD; T20.34XS; T20.35XA; T20.35XD; T20.35XS; T20.36XA; T20.36XD; T20.36XS; T20.37XA; T20.37XD; T20.37XS; T20.39XA; T20.39XD; T20.39XS; T20.711A; T20.711D; T20.711S; T20.712A; T20.712D; T20.712S; T20.72XA; T20.72XD; T20.72XS; T20.73XA; T20.73XD; T20.73XS; T2 [...]
- ICD-10-CM Codes that Support Medical Necessity — Abdominal Lipectomy/Panniculectomy (CPT Codes 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839 and 15847): A31.1; A43.1; A46; A48.0; B35.6; B35.8; B37.2; B95.0; B95.1; B95.2; B95.3; B95.4; B95.61; B95.62; B95.7; B96.0; B96.1; B96.3; B96.4; B96.5; B96.6; B96.7; B96.81; B96.82; B96.83; B96.89; I70.231; I70.238; I70.241; I70.248; I70.25; I70.431; I70.441; I70.45; I70.531; I70.541; I70.55; I70.631; I70.641; I70.65; I70.731; I70.741; I70.7 [...]
- ICD-10-CM Codes that Support Medical Necessity — Reconstructive Breast Surgery (CPT Codes 19316, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396): C50.011; C50.012; C50.021; C50.022; C50.111; C50.112; C50.121; C50.122; C50.211; C50.212; C50.221; C50.222; C50.311; C50.312; C50.321; C50.322; C50.411; C50.412; C50.421; C50.422; C50.511; C50.512; C50.521; C50.522; C50.611; C50.612; C50.621; C50.622; C50.811; C50.812; C50.821; C50. [...]
- ICD-10-CM Codes that Support Medical Necessity — Reduction Mammoplasty (CPT Code 19318): Three diagnoses are required for payment (One primary and two secondary). Primary ICD-10-CM: N62; N65.1. Secondary ICD-10-CMs (two required from Group 5): L26; L30.4; L53.8; L54; L92.0; L95.1; L98.2; M25.511; M25.512; M40.04; M53.81; M53.82; M53.83; M53.84; M54.2; M54.6; M54.89; M54.9; M95.4; N64.4; R20.2; R21; Z85.3. [...]
- ICD-10-CM Codes that Support Medical Necessity — Rhinoplasty (CPT Codes 30400-30450): C30.0; C41.0; C43.31; C43.39; C44.311; C44.319; C44.321; C44.329; C44.391; C44.399; C76.0; D03.39; D04.39; D14.0; D16.4; D22.39; D23.39; J34.0; J34.1; J34.89; S02.2XXA; S02.2XXB; S02.2XXD; S02.2XXG; S02.2XXK; S02.2XXS.
- Reconstructive surgery is covered for abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease when performed to improve function or approximate normal appearance.
20 Active Policies
A58774 — Billing and Coding: Cosmetic and Reconstructive Surgery
J05
L39051 — Cosmetic and Reconstructive Surgery
J05
A59299 — Billing and Coding: Cosmetic and Reconstructive Surgery
L35163 — Plastic Surgery
L39506 — Cosmetic and Reconstructive Surgery
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.