Cosmetic and Reconstructive Services and Procedures

Cosmetic and Reconstructive Services and Procedures Page 1 of 13 UnitedHealthcare Medicare Advantage Policy Guideline Approved 05/10/2017

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COSMETIC AND RECONSTRUCTIVE

SERVICES AND PROCEDURES Guideline Number: MPG065.03 Approval Date: May 10, 2017 Table of Contents Page INSTRUCTIONS FOR USE .......................................... 1 POLICY SUMMARY .................................................... 1 APPLICABLE CODES ................................................. 5 DEFINITIONS ......................................................... 10 QUESTIONS AND ANSWERS ..................................... 12 REFERENCES .......................................................... 12 GUIDELINE HISTORY/REVISION INFORMATION .......... 13

INSTRUCTIONS FOR USE

This Policy Guideline is applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates for health care services submitted on CMS 1500 forms and, when specified, to those billed on UB04 forms (CMS 1450), or their electronic comparative. The information presented in this Policy Guideline is believed to be accurate and current as of the date of publication.

This Policy Guideline provides assistance in administering health benefits. All reviewers must first identify member eligibility, any federal or state regulatory requirements, Centers for Medicare and Medicaid Services (CMS) policy, the member specific benefit plan coverage, and individual provider contracts prior to use of this Policy Guideline. When deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific benefit plan document may differ greatly from the standard benefit plan upon which this Policy Guideline is based. In the event of a conflict, the member specific benefit plan document supersedes this Policy Guideline. Other Policies and Guidelines may apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Policies and Guidelines

as necessary. UnitedHealthcare follows Medicare coverage guidelines and regularly updates its Medicare Advantage Policy Guidelines to comply with changes in CMS policy. UnitedHealthcare encourages physicians and other healthcare professionals to keep current with any CMS policy changes and/or billing requirements by referring to the CMS or your local carrier website regularly. Physicians and other healthcare professionals can sign up for regular distributions for policy or regulatory changes directly from CMS and/or your local carrier. This Policy Guideline is provided for informational

purposes. It does not constitute medical advice. POLICY SUMMARY Overview The purpose of this policy is to clarify the Medicare coverage of cosmetic vs. reconstructive surgical procedures.

Section 1862(a) (1) (A) of Title XVIII of the Social Security Act provides in part that "...no payment may be made under Part A or B (of Medicare) for any expenses incurred for items or services which...are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member."

Related Medicare Advantage Policy Guidelines

Blepharoplasty

Breast Reconstruction Following Mastectomy (NCD 140.2)

Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS) (NCD 250.5)

Dysphoria and Gender Reassignment Surgery (NCD 140.9)

Plastic Surgery to Correct Moon Face (NCD 140.4)

Treatment of Actinic Keratosis (NCD 250.4)

Related Medicare Advantage Coverage Summaries

Blepharoplasty and Related Procedures

Breast Reconstruction Following Mastectomy

Cosmetic and Reconstructive Procedures

UnitedHealthcare Medicare Advantage Policy Guideline

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Guidelines According to the American Society of Plastic and Reconstructive Surgeons, the specialty of plastic surgery includes cosmetic and reconstructive procedures: 1. Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's

appearance and self-esteem. 2. 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 Clinical Indications Surgery performed to treat psychiatric or emotional problems is generally not covered;

Corrective facial surgery is usually not covered when there is no functional impairment present; A mastopexy performed primarily to lift or reshape the breast and unrelated to breast reconstruction following

surgery for breast cancer; Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit. A reduction

mammoplasty is the surgical reshaping of the breasts to reduce or lift enlarged or sagging breasts to improve the appearance of the breast. Cosmetic signs and/or symptoms would include ptosis, poorly fitting clothing and

beneficiary perception of unacceptable appearance. Suction assisted lipectomy to remove localized collections of unwanted fat in order to improve appearance;

Eye surgery that does not correct a functional impairment; Reimbursement for a non-covered procedure performed at the same operative session as a covered surgical

procedure will not be allowed; Mastectomy for gynecomastia when the tissue removed is primarily fatty tissue; Nasal surgery performed solely to improve the patient's appearance in the absence of any signs and/or symptoms

of functional abnormalities; Rhinoplasty is not covered when performed for either of the following indications:

o Solely for the purpose of changing appearance. o As a primary treatment for an obstructive sleep disorder.

Excision, excessive skin and subcutaneous tissue (including lipectomy); abdomen (abdominoplasty) when performed to improve the patient's appearance;

Chemical Peel when done for a cosmetic reason;

Dermabrasion, segmental, face when performed for a cosmetic reason (i.e., post-acne scarring); and Rhytidectomy when performed for a cosmetic reason Abdominoplasty or panniculectomy are not covered when performed primarily for any of the following indications

because it is considered not medically necessary (this list may not be all-inclusive):

o Treatment of neck or back pain o Improving appearance (i.e., cosmesis)

o Repairing abdominal wall laxity or diastasis recti o Treating psychological symptomatology or psychosocial complaints o When performed in conjunction with abdominal or gynecological procedures (e.g., abdominal hernia repair,

hysterectomy, obesity surgery) unless criteria for panniculectomy and abdominoplasty are met separately. Reconstructive Clinical Indications Surgical procedures to replace absent breast tissue secondary to prior tumor removal, trauma, infection or to

correct a gross variation in breast size, that is developmental or post-mastectomy; Breast reconstruction of the affected and the contralateral unaffected breast following a medically necessary

mastectomy; Breast augmentation or reduction mammoplasty is covered in the presence of an acquired deformity of the breast

and breast carcinoma; 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/or to

reduce the size of a normal breast to bring it in symmetry with a breast reconstructed after cancer surgery; 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: o Back and neck or shoulder pain from macromastia and unrelieved by 6 months of:

Conservative analgesia, Supportive measures (garment, etc.),

Physical Therapy, or o Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent

symptoms and/or significant restriction of activity o Intertriginous maceration or infection of the inflammatory skin refractory to dermatologic measures o Permanent shoulder grooving with skin irritation by supporting garment (bra strap)



Removal or revision of breast implant is considered medically necessary when it is removed for one of the following reasons: o Mechanical complication of breast prosthesis; including rupture or failed implant; o Infection or inflammatory reaction due to breast prosthesis; including infected breast implant, or rejection of

breast implants; o Implant extrusion; o Siliconoma or granuloma; o Interference with diagnosis of breast cancer; o Breast pain; and o Painful capsular contracture with disfigurement.

Mastectomy for gynecomastia 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) or symmetric hairline replacement following a burn injury or tumor removal

Chemical Peel is covered for the treatment of actinic keratosis Segmental dermabrasion of the 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 (See Pub. 100-03, NCD, chapter 1, section 250.5, for specific coverage criteria. See Pub. 100-04, Claims Processing Manual, chapter 32, section 260, for specific claims payment/coding instructions)

Surgical removal of excessive fat and skin from the abdomen when the surgery is to alleviate complicating factors

such as: o Inability to walk normally; o Chronic pain; and o Ulceration or infection created by the abdominal skin fold or dermatitis.

Excision, excessive skin and subcutaneous tissue (including lipectomy); abdomen (abdominoplasty) will be considered reasonable and medically necessary when these procedures are performed due to another surgery being done at the same time and would affect the healing of the surgical incision. This procedure may also be

covered 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

Suction assisted lipectomy to remove a lipoma, unless lipoma is the etiology of critical symptoms or other disease

such as erosion, obstruction of contiguous structure; Repair of the upper eyelid when skin is sufficiently low to produce functional complaints, causing visual field

impairment; and Nasal surgery generally performed to improve the following:

o Respiratory function due to airway obstruction or stricture; o Correct anatomic abnormalities caused by birth defects or disease, or revise structural deformities produced

by trauma; o Revise structural deformities due to nasal cutaneous disease; o Treat congenital anatomic anomalies; such as cleft lip nasal deformities, choanal atresia, and oronasal or

oromaxillary fistula; and o Replace nasal tissue lost after tumor ablation.

Rhinoplasty when there is photographic documentation (all of the following: frontal, lateral and worms eye view) of the individuals condition, and the procedure is performed for correction or repair of any of the following: o Nasal deformity secondary to a cleft lip/palate or other congenital craniofacial deformity causing a functional

impairment.

o Chronic, nonseptal, nasal obstruction due to vestibular stenosis (i.e., collapsed internal valves).

o Secondary to trauma, disease, congenital defect with nasal airway obstruction unresponsive to a recent trial of conservative medical management lasting at least six weeks that has either not resolved after previous septoplasty/turbinectomy or would not be expected to resolve with septoplasty/turbinectomy alone.

Septoplasty is considered medically necessary when performed for any of the following indications: o Septal deviation causing nasal airway obstruction that has proved unresponsive to a recent trial of

conservative medical management lasting at least six weeks.

o Recurrent sinusitis secondary to a deviated septum that does not resolve after appropriate medical and antibiotic therapy.

o Recurrent epistaxis related to a septal deformity. o Asymptomatic septal deformity that prevents access to other transnasal areas when such access is required to

perform medically necessary procedures (e.g., ethmoidectomy). o Performed in association with cleft lip or cleft palate repair.



o Obstructed nasal breathing due to septal deformity or deviation that has proved unresponsive to medical management and is interfering with the effective use of medically necessary Continuous Positive Airway Pressure (CPAP) for the treatment of an obstructive sleep disorder.

Flaps (Skin and/or Deep Tissues) Procedures: 15570 - 15738 The regions listed refer to a donor site when a tube is formed for later transfer or when a delay of flap occurs

prior to the transfer. Codes 15732 15738 are described by donor site of the muscle, myocutaneous or fasciocutaneous flap

A repair of a donor site requiring a skin graft or local flaps is considered an additional separate procedure CPT codes 15756 15758 represent microvascular flaps CPT codes 15570 15576 represent flaps without inclusion of a vascular pedicle

CPT codes 14000 14302 represent flaps for adjacent tissue transfer Regions listed in adjacent tissue transfer codes refer to recipient area (not the donor site) when a flap is being

attached in a transfer or to a final site Codes 15570 15738 do not include extensive immobilization (e.g., large plaster casts and other immobilizing

devices are considered additional separate procedures)

Other Flaps and Grafts Procedures: 15740 15777 For code 15740, the physician forms an island pedicle flap. A defect is covered by elevation of a flap of skin and

subcutaneous tissue from a nearby but not immediately adjacent donor site. The flap involves an anatomically named blood vessel in its creation. Often this tissue will be transferred through a tunnel underneath the skin and sutured into its new position. The donor site is closed directly.

Neurovascular pedicle procedures are reported with 15750. Report 15750 if the pedicle is neurovascular, containing functional motor or sensory nerve(s) and blood vessel elements. A neurovascular pedicle flap (15750)

is a type of graft where the pedicle consists of the artery and vein that provide the blood supply and includes the nerve as well. This flap serves to re-innervate a damaged portion of the body dependent on touch or movement (e.g., thumb). The flap is typically transferred through a tunnel underneath the skin and sutured into its new position.

In both cases, repair of the donor site that requires a skin graft or local flaps is considered an additional, separate procedure and should be coded separately. Extensive immobilization and/or repair of the donor site is reported separately.

For random island flaps, V-Y subcutaneous flaps, advancement flaps and other flaps from adjacent areas without clearly defined anatomically named axial vessels; see 14000 14302.

Documentation Requirements

Reduction Mammoplasty documentation should include the evaluation and management note for the date of service and the note for the day the decision to perform surgery was made. The beneficiary's medical record must contain,

and be available for review on request, the following information: 1. Height and weight 2. Body Surface Area (BSA) 3. Clinical evaluation of the signs and/or symptoms ascribed to the macromastia, therapies prior to reduction

mammoplasty and the responses to these therapies. 4. The operative report with documentation of the weight of tissue removed from each breast, obtained in the

operating room.

5. The pathology report with the weight of the tissue removed from each breast. 6. Documentation of back or neck or shoulder pain from macromastia that was unrelieved by 6 months of

conservative analgesia, supportive measures (garment, etc.), and physical therapy. Abdominoplasty documentation must contain a description of the pannus and the underlying skin and a description of conservative treatment undertaken and the results of that treatment. The medical record should also include the

evaluation and management note in which the decision to perform surgery was made, surgical note and any notes

indicating medical complications necessitating the surgery. Rhytidectomy documentation should include the evaluation and management note in which the decision to perform surgery was made, surgical note and any notes documenting the functional impairment. Pre-operative photographs must be made available upon UnitedHealthcare request for punch graft hair transplants.

Documentation in the progress notes for tattooing, to correct color defects of the skin must indicate the prior condition i.e. post-mastectomy, trauma necessitating the reconstruction.



For dermal injections, the medical record must contain evidence of the diagnosis of HIV and treatment with Highly Active Antiretroviral Therapy (HAART). In addition, description of facial abnormalities consistent with LDS must be present as well as description of depressive symptoms.

Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare Services "related to" cosmetic surgery including services related to follow-up care and complications of non-covered services which require treatment during a hospital stay, in which the non-covered service was performed, are not covered services under Medicare. All submitted non-covered or no payment claims using condition code 21 will be processed to completion, and all services on those claims, since they are submitted as non-covered, will be denied. The default liability for payment of

these claims is assigned to the beneficiary, who may then submit the denial from UnitedHealthcare, as the primary payer, to subsequent payer(s) for consideration. After a beneficiary has been discharged from the hospital stay in which the beneficiary received non-covered services, medical and hospital services required to treat a condition or complication that arises as a result of the prior non-covered services may be covered when they are reasonable and necessary in all other respects. Thus, coverage could

be provided for subsequent inpatient stays or outpatient treatment ordinarily covered by Medicare, even if the need for treatment arose because of a previous non-covered procedure. Some examples of services that may be found to

be covered under this policy are the reversal of intestinal bypass surgery for obesity, repair of complications from breast augmentation surgery, removal of a non-covered breast prosthesis, or treatment of any infection at the surgical site of a cosmetic procedure that occurred following discharge from the hospital. However, any subsequent services that could be expected to have been incorporated into a global fee are not covered.

Thus, where a patient undergoes cosmetic surgery and the treatment regimen calls for a series of postoperative visits to the surgeon for evaluating the patient's progress, these visits are not covered. APPLICABLE CODES The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service.

Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.

Coding Clarification: For Rhytidectomy CPT Codes, see the Medicare Advantage Policy Guideline Plastic Surgery to Correct Moon Face (NCD 140.4).

CPT Code Description

Abdominal Lipectomy/Panniculectomy (See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9))

15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy

15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen

(e.g., abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)

Adjacent Tissue Transfer (See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9))

14000 Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less

14001 Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm

14020 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less

14021 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm

14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less

14041 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm

14060 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less

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Adjacent Tissue Transfer: See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)

14061 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect

10.1 sq cm to 30.0 sq cm

14301 Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm

14302 Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure)

Biologic Implant

15777 Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (List separately in addition to code for primary procedure)

Breast Surgery: See the Medicare Advantage Policy Guideline titled Breast Reconstruction Following Mastectomy (NCD 140.2) for breast reconstruction CPT codes

19316 Mastopexy [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

19324 Mammaplasty, augmentation; without prosthetic implant [See also the Medicare

Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

19325 Mammaplasty, augmentation; with prosthetic implant [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

19355 Correction of inverted nipples

Chemical Peel: See also the Medicare Advantage Policy Guidelines titled Dysphoria and Gender Reassignment Surgery (NCD 140.9) and Treatment of Actinic Keratosis (NCD 250.4)

15788 Chemical peel, facial; epidermal

15789 Chemical peel, facial; dermal

15792 Chemical peel, nonfacial; epidermal

15793 Chemical peel, nonfacial; dermal

Dermabrasion: See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)

15780 Dermabrasion total face

15781 Dermabrasion; segmental, face

15782 Dermabrasion other than face

15783 Dermabrasion superficial any site

Hair Transplant: See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)

15775 Punch graft for hair transplant; 1 to 15 punch grafts

15776 Punch graft for hair transplant; more than 15 punch grafts

Mastectomy for Gynecomastia

19300 Mastectomy for gynecomastia

Myocutaneous Flaps

15570 Formation of direct or tubed pedicle, with or without transfer; trunk

15572 Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legs

15574 Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet

15576 Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral

15731 Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap)

15732 Muscle, myocutaneous, or fasciocutaneous flap; head and neck (e.g., temporalis, masseter muscle, sternocleidomastoid, levator scapulae)

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Myocutaneous Flaps

15734 Muscle, myocutaneous, or fasciocutaneous flap; trunk [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD

140.9)]

15736 Muscle, myocutaneous, or fasciocutaneous flap; upper extremity

15738 Muscle, myocutaneous, or fasciocutaneous flap; lower extremity [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

15740 Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel

15750 Flap; neurovascular pedicle [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

15756 Free muscle or myocutaneous flap with microvascular anastomosis

15757 Free skin flap with microvascular anastomosis [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

15758 Free fascial flap with microvascular anastomosis [See also the Medicare Advantage

Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

Reduction Mammoplasty: See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)

19318 Reduction mammoplasty

Rhinoplasty

30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and

alar cartilages, and/or elevation of nasal tip [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

30420 Rhinoplasty, primary; including major septal repair [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work) [See also

the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

30435 Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) [See

also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

30450 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

30460 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only

30462 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies

Tattooing

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)

Cosmetic: The below CPT codes are always considered cosmetic and are never covered.

11950 Subcutaneous injection of filling material (e.g., collagen); 1 cc or less [See also the

Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

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11951 Subcutaneous injection of filling material (e.g., collagen); 1.1 to 5.0 cc [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment

Surgery (NCD 140.9)]

11952

Subcutaneous injection of filling material (e.g., collagen); 5.1 to 10.0 cc [See also


11954 Subcutaneous injection of filling material (e.g., collagen); over 10.0 cc [See also the


15786 Abrasion; single lesion (e.g., keratosis, scar)

15787 Abrasion; each additional 4 lesions or less (list separately in addition to code for primary procedure)

15819 Cervicoplasty [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

15832 Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

15833

Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg [See also


15834 Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip [See also


15835 Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

15836 Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm [See also


15837 Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or

hand [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

15838 Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

15839 Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area

[See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

15876 Suction assisted lipectomy; head and neck [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

15877 Suction assisted lipectomy; trunk [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

15878 Suction assisted lipectomy; upper extremity [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

15879 Suction assisted lipectomy; lower extremity [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

17380 Electrolysis epilation, each 30 minutes [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

21120 Genioplasty; augmentation (autograft, allograft, prosthetic material) [See also the


21121 Genioplasty; sliding osteotomy, single piece [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

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21122 Genioplasty; Sliding Osteotomies, 2 Or More Osteotomies (e.g., Wedge Excision Or Bone Wedge Reversal For Asymmetrical Chin) [See also the Medicare Advantage

Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

21123

Genioplasty; sliding, augmentation with interpositional bone grafts (includes

obtaining autografts) [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

21125 Augmentation, mandibular body or angle; prosthetic material [See also the Medicare

Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

21137 Reduction forehead; contouring only [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

21138

Reduction forehead; contouring and application of prosthetic material or bone graft

(includes obtaining autograft) [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

21139 Reduction forehead; contouring and setback of anterior frontal sinus wall [See also


21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)

[See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

21209 Osteoplasty, facial bones; reduction [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

21270 Malar augmentation, prosthetic material [See also the Medicare Advantage Policy Guideline titled Dysphoria and Gender Reassignment Surgery (NCD 140.9)]

21280 Medial canthopexy (separate procedure)

21282 Lateral canthopexy

21295 Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approach

21296 Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach

30120 Excision or surgical planing of skin of nose for rhinophyma

36468 Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk

40500 Vermilionectomy (lip shave), with mucosal advancement

69090 Ear piercing

69300 Otoplasty, protruding ear, with or without size reduction

CPT is a registered trademark of the American Medical Association

HCPCS Code Description

Dermal Injections: See also the Medicare Advantage Policy Guideline titled Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS) (NCD 250.5)

C9800 Dermal injection procedure(s) for facial lipodystrophy syndrome (LDS) and provision

of Radiesse or Sculptra dermal filler, including all items and supplies (Expired 12/31/2016 See G0429)

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

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Anesthesia Code Description

Abdominal Lipectomy/Panniculectomy

00802 Anesthesia for procedures on lower anterior abdominal wall; panniculectomy

Breast Surgery

00402

Anesthesia for procedures on the integumentary system on the extremities, anterior

trunk and perineum; reconstructive procedures on breast (e.g., reduction or augmentation mammoplasty, muscle flaps)

Revenue Code Description

036X Operating Room Services - General Classification

045X Emergency Room - General Classification

049X Ambulatory Surgical Care - General Classification

051X Clinic - General Classification

052X Free-Standing Clinic - General Classification

076X Specialty Services - General Classification

Bill Type Description

011x Hospital Inpatient (Including Medicare Part A)

013x Hospital Outpatient

071x Clinic - Rural Health

073x Clinic - Freestanding

077x Clinic - Federally Qualified Health Center (FQHC)

083x Ambulatory Surgery Center

085x Critical Access Hospital

ICD-10 Diagnosis Codes

Cosmetic ICD-10 Dx Coding.xls

ICD-10 Procedure Code Description

Breast Surgery

0HST0ZZ Reposition Right Breast, Open Approach

0HSU0ZZ Reposition Left Breast, Open Approach

0HSV0ZZ Reposition Bilateral Breast, Open Approach

0H0T0ZZ Alteration of Right Breast, Open Approach

0H0U0ZZ Alteration of Left Breast, Open Approach

0H0V0ZZ Alteration of Bilateral Breast, Open Approach

DEFINITIONS

Abdominoplasty: A procedure typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty. Cervicoplasty: The physician removes excess skin from the neck area. The physician marks the area to be removed. The skin is incised and the excess tissue is resected. The skin is reapproximated and sutured in layers.

Cosmetic: Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patients appearance and self-esteem. Surgery performed to improve on natural appearance or performed purely for the purpose of enhancing ones normal appearance is not considered reasonable and necessary. Functional/Physical Impairment: A physical/functional or physiological impairment causes deviation from the

normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move,

Ab Lipectomy Panniculectomy

Abdominal Lipectomy/Panniculectomy CPT codes 15830 and 15847

ICD-10 Diagnosis CodeDescription

A31.1Cutaneous mycobacterial infection

A43.1Cutaneous nocardiosis

A46Erysipelas

A48.0Gas gangrene

B35.6Tinea cruris

B35.8Other dermatophytoses

B95.0Streptococcus, group A, as the cause of diseases classified elsewhere

B95.1Streptococcus, group B, as the cause of diseases classified elsewhere

B95.2Enterococcus as the cause of diseases classified elsewhere

B95.3Streptococcus pneumoniae as the cause of diseases classified elsewhere

B95.4Other streptococcus as the cause of diseases classified elsewhere

B95.61Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere

B95.62Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere

B95.7Other staphylococcus as the cause of diseases classified elsewhere

B96.0Mycoplasma pneumoniae [M. pneumoniae] as the cause of diseases classified elsewhere

B96.1Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere

B96.3Hemophilus influenzae [H. influenzae] as the cause of diseases classified elsewhere

B96.4Proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere

B96.5Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere

B96.6Bacteroides fragilis [B. fragilis] as the cause of diseases classified elsewhere

B96.7Clostridium perfringens [C. perfringens] as the cause of diseases classified elsewhere

B96.81Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere

B96.82Vibrio vulnificus as the cause of diseases classified elsewhere

B96.89Other specified bacterial agents as the cause of diseases classified elsewhere

E65Localized adiposity

K43.0Incisional hernia with obstruction, without gangrene

K43.1Incisional hernia with gangrene

K43.2Incisional hernia without obstruction or gangrene

K43.3Parastomal hernia with obstruction, without gangrene

K43.4Parastomal hernia with gangrene

K43.5Parastomal hernia without obstruction or gangrene

K43.6Other and unspecified ventral hernia with obstruction, without gangrene

K43.7Other and unspecified ventral hernia with gangrene

K43.9Ventral hernia without obstruction or gangrene

K46.9Unspecified abdominal hernia without obstruction or gangrene

L08.1Erythrasma

L30.4Erythema intertrigo

L87.9Transepidermal elimination disorder, unspecified

L90.9Atrophic disorder of skin, unspecified

L91.9Hypertrophic disorder of the skin, unspecified

L98.411Non-pressure chronic ulcer of buttock limited to breakdown of skin

L98.412Non-pressure chronic ulcer of buttock with fat layer exposed

L98.413Non-pressure chronic ulcer of buttock with necrosis of muscle

L98.414Non-pressure chronic ulcer of buttock with necrosis of bone

L98.419Non-pressure chronic ulcer of buttock with unspecified severity

L98.421Non-pressure chronic ulcer of back limited to breakdown of skin

L98.422Non-pressure chronic ulcer of back with fat layer exposed

L98.423Non-pressure chronic ulcer of back with necrosis of muscle

L98.424Non-pressure chronic ulcer of back with necrosis of bone

L98.429Non-pressure chronic ulcer of back with unspecified severity

M35.6Relapsing panniculitis [Weber-Christian]

M79.3Panniculitis, unspecified

Breast Surgery

Breast Surgery CPT codes 19324, 19325, 19355

ICD-10 Procedure Codes 0H0T0ZZ, 0H0U0ZZ, 0H0V0ZZ


C44.501Unspecified malignant neoplasm of skin of breast

C44.511Basal cell carcinoma of skin of breast

C44.521Squamous cell carcinoma of skin of breast

C44.591Other specified malignant neoplasm of skin of breast

C50.011Malignant neoplasm of nipple and areola, right female breast

C50.012Malignant neoplasm of nipple and areola, left female breast

C50.021Malignant neoplasm of nipple and areola, right male breast

C50.022Malignant neoplasm of nipple and areola, left male breast

C50.111Malignant neoplasm of central portion of right female breast

C50.112Malignant neoplasm of central portion of left female breast

C50.121Malignant neoplasm of central portion of right male breast

C50.122Malignant neoplasm of central portion of left male breast

C50.211Malignant neoplasm of upper-inner quadrant of right female breast

C50.212Malignant neoplasm of upper-inner quadrant of left female breast

C50.221Malignant neoplasm of upper-inner quadrant of right male breast

C50.222Malignant neoplasm of upper-inner quadrant of left male breast

C50.311Malignant neoplasm of lower-inner quadrant of right female breast

C50.312Malignant neoplasm of lower-inner quadrant of left female breast

C50.321Malignant neoplasm of lower-inner quadrant of right male breast

C50.322Malignant neoplasm of lower-inner quadrant of left male breast

C50.411Malignant neoplasm of upper-outer quadrant of right female breast

C50.412Malignant neoplasm of upper-outer quadrant of left female breast

C50.421Malignant neoplasm of upper-outer quadrant of right male breast

C50.422Malignant neoplasm of upper-outer quadrant of left male breast

C50.511Malignant neoplasm of lower-outer quadrant of right female breast

C50.512Malignant neoplasm of lower-outer quadrant of left female breast

C50.521Malignant neoplasm of lower-outer quadrant of right male breast

C50.522Malignant neoplasm of lower-outer quadrant of left male breast

C50.611Malignant neoplasm of axillary tail of right female breast

C50.612Malignant neoplasm of axillary tail of left female breast

C50.621Malignant neoplasm of axillary tail of right male breast

C50.622Malignant neoplasm of axillary tail of left male breast

C50.811Malignant neoplasm of overlapping sites of right female breast

C50.812Malignant neoplasm of overlapping sites of left female breast

C50.821Malignant neoplasm of overlapping sites of right male breast

C50.822Malignant neoplasm of overlapping sites of left male breast

C50.911Malignant neoplasm of unspecified site of right female breast

C50.912Malignant neoplasm of unspecified site of left female breast

C50.921Malignant neoplasm of unspecified site of right male breast

C50.922Malignant neoplasm of unspecified site of left male breast

C79.2Secondary malignant neoplasm of skin

C79.81Secondary malignant neoplasm of breast

D04.5Carcinoma in situ of skin of trunk

D05.01Lobular carcinoma in situ of right breast

D05.02Lobular carcinoma in situ of left breast

D05.11Intraductal carcinoma in situ of right breast

D05.12Intraductal carcinoma in situ of left breast

D05.81Other specified type of carcinoma in situ of right breast

D05.82Other specified type of carcinoma in situ of left breast

D05.91Unspecified type of carcinoma in situ of right breast

D05.92Unspecified type of carcinoma in situ of left breast

D24.1Benign neoplasm of right breast

D24.2Benign neoplasm of left breast

D24.9Benign neoplasm of unspecified breast

D48.60Neoplasm of uncertain behavior of unspecified breast

D48.61Neoplasm of uncertain behavior of right breast

D48.62Neoplasm of uncertain behavior of left breast

D49.3Neoplasm of unspecified behavior of breast

N60.01Solitary cyst of right breast

N60.02Solitary cyst of left breast

N60.11Diffuse cystic mastopathy of right breast

N60.12Diffuse cystic mastopathy of left breast

N60.21Fibroadenosis of right breast

N60.22Fibroadenosis of left breast

N60.31Fibrosclerosis of right breast

N60.32Fibrosclerosis of left breast

N60.41Mammary duct ectasia of right breast

N60.42Mammary duct ectasia of left breast

N60.81Other benign mammary dysplasias of right breast

N60.82Other benign mammary dysplasias of left breast

N60.91Unspecified benign mammary dysplasia of right breast

N60.92Unspecified benign mammary dysplasia of left breast

N61.1Abscess of the breast and nipple

N64.89Other specified disorders of breast

N65.0Deformity of reconstructed breast

N65.1Disproportion of reconstructed breast

T85.41XABreakdown (mechanical) of breast prosthesis and implant, initial encounter

T85.41XDBreakdown (mechanical) of breast prosthesis and implant, subsequent encounter

T85.41XSBreakdown (mechanical) of breast prosthesis and implant, sequela

T85.42XADisplacement of breast prosthesis and implant, initial encounter

T85.42XDDisplacement of breast prosthesis and implant, subsequent encounter

T85.42XSDisplacement of breast prosthesis and implant, sequela

T85.43XALeakage of breast prosthesis and implant, initial encounter

T85.43XDLeakage of breast prosthesis and implant, subsequent encounter

T85.43XSLeakage of breast prosthesis and implant, sequela

T85.44XACapsular contracture of breast implant, initial encounter

T85.44XDCapsular contracture of breast implant, subsequent encounter

T85.44XSCapsular contracture of breast implant, sequela

T85.49XAOther mechanical complication of breast prosthesis and implant, initial encounter

T85.49XDOther mechanical complication of breast prosthesis and implant, subsequent encounter

T85.49XSOther mechanical complication of breast prosthesis and implant, sequela

T85.79XAInfection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter

T85.79XDInfection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, subsequent encounter

T85.79XSInfection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, sequela

Z42.1Encounter for breast reconstruction following mastectomy

Z44.30Encounter for fitting and adjustment of external breast prosthesis, unspecified breast

Z44.31Encounter for fitting and adjustment of external right breast prosthesis

Z44.32Encounter for fitting and adjustment of external left breast prosthesis

Z45.811Encounter for adjustment or removal of right breast implant

Z45.812Encounter for adjustment or removal of left breast implant

Z45.819Encounter for adjustment or removal of unspecified breast implant

Z48.3Aftercare following surgery for neoplasm

Z85.3Personal history of malignant neoplasm of breast

Z90.11Acquired absence of right breast and nipple

Z90.12Acquired absence of left breast and nipple

Z90.13Acquired absence of bilateral breasts and nipples

Z98.82Breast implant status

Chemical Peel

Chemical Peel CPT codes 15788, 15789, 15792, 15793


L57.0Actinic keratosis

Dermabrasion

Dermabrasion CPT codes 15780, 15781, 15782, 15783


L71.0Perioral dermatitis

L71.1Rhinophyma

L71.8Other rosacea

L71.9Rosacea, unspecified

Hair Transplant

Hair Transplant CPT codes 15775, 15776


C44.300Unspecified malignant neoplasm of skin of unspecified part of face

C44.309Unspecified malignant neoplasm of skin of other parts of face

C44.310Basal cell carcinoma of skin of unspecified parts of face

C44.319Basal cell carcinoma of skin of other parts of face

C44.320Squamous cell carcinoma of skin of unspecified parts of face

C44.329Squamous cell carcinoma of skin of other parts of face

C44.390Other specified malignant neoplasm of skin of unspecified parts of face

C44.399Other specified malignant neoplasm of skin of other parts of face

D04.30Carcinoma in situ of skin of unspecified part of face

D04.39Carcinoma in situ of skin of other parts of face

D04.8Carcinoma in situ of skin of other sites

D22.30Melanocytic nevi of unspecified part of face

D22.39Melanocytic nevi of other parts of face

D23.30Other benign neoplasm of skin of unspecified part of face

D23.39Other benign neoplasm of skin of other parts of face

D48.5Neoplasm of uncertain behavior of skin

S09.10XAUnspecified injury of muscle and tendon of head, initial encounter

S09.10XDUnspecified injury of muscle and tendon of head, subsequent encounter

S09.10XSUnspecified injury of muscle and tendon of head, sequela

S09.11XAStrain of muscle and tendon of head, initial encounter

S09.11XDStrain of muscle and tendon of head, subsequent encounter

S09.11XSStrain of muscle and tendon of head, sequela

S09.19XAOther specified injury of muscle and tendon of head, initial encounter

S09.19XDOther specified injury of muscle and tendon of head, subsequent encounter

S09.19XSOther specified injury of muscle and tendon of head, sequela

S09.8XXAOther specified injuries of head, initial encounter

S09.8XXDOther specified injuries of head, subsequent encounter

S09.8XXSOther specified injuries of head, sequela

T20.06XABurn of unspecified degree of forehead and cheek, initial encounter

T20.06XDBurn of unspecified degree of forehead and cheek, subsequent encounter

T20.06XSBurn of unspecified degree of forehead and cheek, sequela

T20.16XABurn of first degree of forehead and cheek, initial encounter

T20.16XDBurn of first degree of forehead and cheek, subsequent encounter

T20.16XSBurn of first degree of forehead and cheek, sequela

T20.26XABurn of second degree of forehead and cheek, initial encounter

T20.26XDBurn of second degree of forehead and cheek, subsequent encounter

T20.26XSBurn of second degree of forehead and cheek, sequela

T20.36XABurn of third degree of forehead and cheek, initial encounter

T20.36XDBurn of third degree of forehead and cheek, subsequent encounter

T20.36XSBurn of third degree of forehead and cheek, sequela

T20.66XACorrosion of second degree of forehead and cheek, initial encounter

T20.66XDCorrosion of second degree of forehead and cheek, subsequent encounter

T20.66XSCorrosion of second degree of forehead and cheek, sequela

T20.76XACorrosion of third degree of forehead and cheek, initial encounter

T20.76XDCorrosion of third degree of forehead and cheek, subsequent encounter

T20.76XSCorrosion of third degree of forehead and cheek, sequela

Z48.89Encounter for other specified surgical aftercare

Mastopexy

Mastopexy CPT code 19316

ICD-10 Procedure Codes 0HST0ZZ, 0HSU0ZZ, 0HSV0ZZ

























C50.422Malignant neoplasm of upper-outer quadrant of left male breast


C50.512Malignant neoplasm of lower-outer quadrant of left female breast

C50.521Malignant neoplasm of lower-outer quadrant of right male breast

C50.522Malignant neoplasm of lower-outer quadrant of left male breast

C50.611Malignant neoplasm of axillary tail of right female breast

C50.612Malignant neoplasm of axillary tail of left female breast

C50.621Malignant neoplasm of axillary tail of right male breast

C50.622Malignant neoplasm of axillary tail of left male breast

C50.811Malignant neoplasm of overlapping sites of right female breast

C50.812Malignant neoplasm of overlapping sites of left female breast

C50.821Malignant neoplasm of overlapping sites of right male breast

C50.822Malignant neoplasm of overlapping sites of left male breast

C50.911Malignant neoplasm of unspecified site of right female breast

C50.912Malignant neoplasm of unspecified site of left female breast

C50.921Malignant neoplasm of unspecified site of right male breast

C50.922Malignant neoplasm of unspecified site of left male breast

C79.2Secondary malignant neoplasm of skin

C79.81Secondary malignant neoplasm of breast

D04.5Carcinoma in situ of skin of trunk

D05.01Lobular carcinoma in situ of right breast

D05.02Lobular carcinoma in situ of left breast

D05.11Intraductal carcinoma in situ of right breast

D05.12Intraductal carcinoma in situ of left breast

D05.81Other specified type of carcinoma in situ of right breast

D05.82Other specified type of carcinoma in situ of left breast

D05.90Unspecified type of carcinoma in situ of unspecified breast

D05.91Unspecified type of carcinoma in situ of right breast

D05.92Unspecified type of carcinoma in situ of left breast

D24.1Benign neoplasm of right breast

D24.2Benign neoplasm of left breast

D24.9Benign neoplasm of unspecified breast

D48.60Neoplasm of uncertain behavior of unspecified breast

D48.61Neoplasm of uncertain behavior of right breast

D48.62Neoplasm of uncertain behavior of left breast

D49.3Neoplasm of unspecified behavior of breast

L26Exfoliative dermatitis

L30.4Erythema intertrigo

L53.8Other specified erythematous conditions

L54Erythema in diseases classified elsewhere

L92.0Granuloma annulare

L95.1Erythema elevatum diutinum

L98.2Febrile neutrophilic dermatosis [Sweet]

M25.511Pain in right shoulder

M25.512Pain in left shoulder

M54.2Cervicalgia

M54.6Pain in thoracic spine

M54.89Other dorsalgia

M54.9Dorsalgia, unspecified

N60.01Solitary cyst of right breast

N60.02Solitary cyst of left breast

N60.11Diffuse cystic mastopathy of right breast

N60.12Diffuse cystic mastopathy of left breast

N60.21Fibroadenosis of right breast

N60.22Fibroadenosis of left breast

N60.31Fibrosclerosis of right breast

N60.32Fibrosclerosis of left breast

N60.41Mammary duct ectasia of right breast

N60.42Mammary duct ectasia of left breast

N60.81Other benign mammary dysplasias of right breast

N60.82Other benign mammary dysplasias of left breast

N60.91Unspecified benign mammary dysplasia of right breast

N60.92Unspecified benign mammary dysplasia of left breast

N61.1Abscess of the breast and nipple

N62Hypertrophy of breast

N64.4Mastodynia

N64.89Other specified disorders of breast

N65.0Deformity of reconstructed breast

N65.1Disproportion of reconstructed breast

R21Rash and other nonspecific skin eruption

T85.41XABreakdown (mechanical) of breast prosthesis and implant, initial encounter

T85.41XDBreakdown (mechanical) of breast prosthesis and implant, subsequent encounter

T85.41XSBreakdown (mechanical) of breast prosthesis and implant, sequela

T85.42XADisplacement of breast prosthesis and implant, initial encounter

T85.42XDDisplacement of breast prosthesis and implant, subsequent encounter

T85.42XSDisplacement of breast prosthesis and implant, sequela

T85.43XALeakage of breast prosthesis and implant, initial encounter

T85.43XDLeakage of breast prosthesis and implant, subsequent encounter

T85.43XSLeakage of breast prosthesis and implant, sequela

T85.44XACapsular contracture of breast implant, initial encounter

T85.44XDCapsular contracture of breast implant, subsequent encounter

T85.44XSCapsular contracture of breast implant, sequela

T85.49XAOther mechanical complication of breast prosthesis and implant, initial encounter

T85.49XDOther mechanical complication of breast prosthesis and implant, subsequent encounter

T85.49XSOther mechanical complication of breast prosthesis and implant, sequela

T85.79XAInfection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter

T85.79XDInfection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, subsequent encounter

T85.79XSInfection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, sequela

Z42.1Encounter for breast reconstruction following mastectomy

Z44.30Encounter for fitting and adjustment of external breast prosthesis, unspecified breast

Z44.31Encounter for fitting and adjustment of external right breast prosthesis

Z44.32Encounter for fitting and adjustment of external left breast prosthesis

Z45.811Encounter for adjustment or removal of right breast implant

Z45.812Encounter for adjustment or removal of left breast implant

Z45.819Encounter for adjustment or removal of unspecified breast implant

Z48.3Aftercare following surgery for neoplasm

Z85.3Personal history of malignant neoplasm of breast

Z90.11Acquired absence of right breast and nipple

Z90.12Acquired absence of left breast and nipple

Z90.13Acquired absence of bilateral breasts and nipples

Z98.82Breast implant status

Reduction Mammoplasty

Reduction Mammoplasty CPT code 19318

ICD-10 Procedure Codes 0H0T0ZZ, 0H0U0ZZ, 0H0V0ZZ


























C50.512Malignant neoplasm of lower-outer quad

Cosmetic and Reconstructive Services and Procedures

Documents

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