15782
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
4.33
Facility
$320.31
Non-Facility
$475.63
Documentation Required
- For reduction mammoplasty, the medical record must include height and weight of the beneficiary.
- For reduction mammoplasty, include a clinical evaluation documenting signs and/or symptoms ascribed to macromastia, therapies tried prior to surgery, and responses to those therapies.
- For reduction mammoplasty, document severity and impact on health-related quality of life using an accepted breast-specific questionnaire.
- Operative report must document the weight of tissue removed from each breast (measured in the operating room) and the pathology report for tissue removed must be included in the record.
Key Coverage Criteria
- Reconstructive plastic surgery is covered when performed for therapeutic purposes such as treatment of severe burns, facial repair following auto trauma, or similar reconstructive/therapeutic surgery.
- Reduction mammoplasty is covered when the beneficiary has symptomatic breast hypertrophy (macromastia) with documented severe symptoms and demonstrable adverse impact on health-related quality of life as measured by an accepted breast-specific questionnaire, AND persistent signs/symptoms despite a reasonable trial of conservative therapy.
- 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. [...]
20 Active Policies
L39051 — Cosmetic and Reconstructive Surgery
J05
A58774 — Billing and Coding: Cosmetic and Reconstructive Surgery
J05
A57221 — Billing and Coding: Plastic Surgery
A59299 — Billing and Coding: Cosmetic and Reconstructive Surgery
L35163 — Plastic Surgery
Related Codes
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