Procedure Codes and Description
Group 1 Paragraph: N/A
Group 1 Codes:
11920 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.0 SQ CM OR LESS
11921 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.1 TO 20.0 SQ CM
11922 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; EACH ADDITIONAL 20.0 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
15775 – 15776 PUNCH GRAFT FOR HAIR TRANSPLANT; 1 TO 15 PUNCH GRAFTS – PUNCH GRAFT FOR HAIR TRANSPLANT; MORE THAN 15 PUNCH GRAFTS
15781 DERMABRASION; SEGMENTAL, FACE
15788 – 15793 CHEMICAL PEEL, FACIAL; EPIDERMAL – CHEMICAL PEEL, NONFACIAL; DERMAL
15828 RHYTIDECTOMY; CHEEK, CHIN, AND NECK
15829 RHYTIDECTOMY; SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM (SMAS) FLAP
15830 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY
19300 MASTECTOMY FOR GYNECOMASTIA
19316 MASTOPEXY
19318 REDUCTION MAMMAPLASTY
19324 MAMMAPLASTY, AUGMENTATION; WITHOUT PROSTHETIC IMPLANT
19325 MAMMAPLASTY, AUGMENTATION; WITH PROSTHETIC IMPLANT
19328 REMOVAL OF INTACT MAMMARY IMPLANT
19330 REMOVAL OF MAMMARY IMPLANT MATERIAL
19340 IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION
19342 DELAYED INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION
19350 NIPPLE/AREOLA RECONSTRUCTION
19355 CORRECTION OF INVERTED NIPPLES
19357 BREAST RECONSTRUCTION, IMMEDIATE OR DELAYED, WITH TISSUE EXPANDER, INCLUDING SUBSEQUENT EXPANSION
19361 BREAST RECONSTRUCTION WITH LATISSIMUS DORSI FLAP, WITHOUT PROSTHETIC IMPLANT
19364 BREAST RECONSTRUCTION WITH FREE FLAP
19366 BREAST RECONSTRUCTION WITH OTHER TECHNIQUE
19367 BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP (TRAM), SINGLE PEDICLE, INCLUDING CLOSURE OF
DONOR SITE;
19368 BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP (TRAM), SINGLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE; WITH MICROVASCULAR ANASTOMOSIS (SUPERCHARGING)
19369 BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP (TRAM), DOUBLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE
19370 OPEN PERIPROSTHETIC CAPSULOTOMY, BREAST
19371 PERIPROSTHETIC CAPSULECTOMY, BREAST
19380 REVISION OF RECONSTRUCTED BREAST
19396 PREPARATION OF MOULAGE FOR CUSTOM BREAST IMPLANT
30400 – 30450 RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES AND/OR ELEVATION OF NASAL TIP – RHINOPLASTY, SECONDARY; MAJOR REVISION (NASAL TIP WORK AND OSTEOTOMIES)
C9800 DERMAL INJECTION PROCEDURE(S) FOR FACIAL LIPODYSTROPHY SYNDROME (LDS) AND PROVISION OF RADIESSE OR SCULPTRA DERMAL FILLER, INCLUDING ALL ITEMS AND SUPPLIES
G0429 DERMAL FILLER INJECTION(S) FOR THE TREATMENT OF FACIAL LIPODYSTROPHY SYNDROME (LDS) (E.G., AS A RESULT OF HIGHLY ACTIVE ANTIRETROVIRAL THERAPY)
Q2026 INJECTION, RADIESSE, 0.1 ML
Q2028 INJECTION, SCULPTRA, 0.5 MG
Coverage Indications, Limitations, and/or Medical Necessity
According to the American Society of Plastic and Reconstructive Surgeons, the specialty of plastic surgery includes reconstructive and cosmetic procedures:
Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.
Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem.
Indications for specific surgical procedures:
Breast reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is covered.
Removal or revision of a breast implant is considered medically necessary when it is removed for one of the following reasons:
Mechanical complication of breast prosthesis; including rupture or failed implant, and/or implant extrusion
Infection or inflammatory reaction due to a breast prosthesis; including infected breast implant, or rejection of breast implants.
Other complication of internal breast implant; including siliconoma, granuloma, interference with diagnosis of breast cancer, and/or painful capsular contracture with disfigurement.
Reduction Mammoplasty is the surgical reshaping of the breasts to reduce or lift enlarged or sagging breasts. Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit.
Macromastia (breast hypertrophy) is an increase in the volume and weight of breast tissue relative to the general body habitus. Breast hypertrophy may adversely affect other body systems: musculoskeletal, respiratory, and integumentary. Unilateral hypertrophy may result in symptoms following contralateral mastectomy.
Medical necessity for a reduction mammoplasty is limited to circumstances in which:
There are signs and/or symptoms resulting from the enlarged breasts (macromastia) that have not responded adequately to non-surgical interventions, and To reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery.
Non-surgical interventions preceding reduction mammoplasty should include as appropriate, but are not limited to, the following:
Determining the macromastia is not due to an active endocrine or metabolic process.
Determining the symptoms are refractory to appropriately fitted supporting garments, or following unilateral mastectomy, persistent with an appropriately fitted prosthesis or reconstruction therapy at the site of the absent breast.
Determining that dermatologic signs and/or symptoms are refractory to, or recurrent following, a completed course of medical management.
A medically reasonable and necessary reduction mammoplasty could be indicated in the presence of significantly enlarged breasts and the presence of at least one of the following signs and/or symptoms:
Back, neck or shoulder pain from macromastia and unrelieved by 6 months of:
Conservative analgesia,
Supportive measures (garment, etc.),
Physical Therapy, or
Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity, or
Intertriginous maceration or infection of the inframammary skin refractory related to dermatologic measures.
Permanent shoulder grooving with skin irritation by supporting garment (bra strap).
The amount of breast tissue to be removed must be proportional to the body surface area (BSA) per the Schnur scale below. If only one breast meets the Schnur scale criteria; breast tissue may be removed from the other breast in order to achieve symmetry.
Schnur Scale:
Body Surface
Area (m2) Average grams of tissue per breast to be removed
1.40-1.50 218-260
1.51–1.60 261-310
1.61-1.70 311-370
1.71-1.80 371-441
1.81-1.90 442-527
1.91-2.00 528-628
2.01-2.10 629-750
2.11-2.20 751-895
2.21-2.30 896-1068
2.31-2.40 1069-1275
2.41-2.50 1276-1522
2.51-2.60 1523-1806
2.61-2.70 1807-2154
2.71-2.80 2155-2568
2.81-2.90 2569-3061
2.91-3.00 3062-3650
Mastectomy for gynecomastia
Gynecomastia is the excessive growth of the male mammary glands. These conditions can cause significant clinical manifestations when the excessive breast weight adversely affects the supporting structures of the shoulders, neck, and trunk. Payment may be made for this procedure if it is documented that the tissue is primarily breast tissue and not just adipose (fatty tissue).
Tattooing to correct color defects of the skin may be considered reconstructive when performed in connection with a payable post-mastectomy reconstruction, or for reconstruction following trauma or removal of cancer from an eyelid, eyebrow or lip(s).
Punch graft hair transplant may be considered reconstructive when it is performed for eyebrow(s) replacement following a burn injury or tumor removal.
Rhinoplasty that is performed to improve nasal respiratory function due to airway obstruction or stricture, repair deficits caused by trauma, revise structural deformities produced by trauma or nasal cutaneous disease, or replace nasal tissue lost after tumor ablative surgery is covered.
Nasal fracture
Benign or malignant neoplasms
Nasal Obstruction
Chemical Peel
Is covered for the treatment of Actinic Keratosis.
Dermabrasion, segmental, face is covered for the treatment of rhinophyma.
Dermal injections for facial LDS using dermal fillers approved by the FDA for this purpose, and then only in HIV-infected Medicare beneficiaries who manifest depression secondary to the physical stigma of HIV treatment will be covered. Effective for claims with dates of service on and after March 23, 2010.
See Pub. 100-03, Medicare National Coverage Determinations Chapter 1, Coverage Determinations Part 4, Section 250.5, for specific coverage criteria. See Pub. 100-04, Claims Processing Manual, Chapter 32, Section 260, for specific claims payment/coding instructions.
The following procedures will be considered on an individual basis.
Rhytidectomy is considered medically necessary to correct a functional impairment as a result of a disease state ie; facial paralysis. Often this procedure is performed in conjunction with other procedures to correct the impairment.
Excision, excessive skin and subcutaneous tissue (including lipectomy); abdomen (abdominoplasty) will only be considered reasonable and medically necessary when these procedures are performed due to another surgery being done at the same time and would effect the healing of the surgical incision.
This procedure may also be considered to be medically necessary for the patient that has had a significant weight-loss following the treatment of morbid obesity and there are medical complications such as candidiasis, intertrigo or tissue necrosis that is unresponsive to oral or topical medication.
These claims will be reviewed by the medical staff and considered on a case by case basis. Medical Records will be requested by the Contractor to determine medical necessity. See Documentation Requirements section of this LCD.
