Question: We recently had a patient come in for a bilateral mastectomy. The left breast had cancer, and surgeons performed a prophylactic removal on the right breast. The CPTÒ code we used was 19303 with diagnosis codes C50.912 and Z40.01. We also used modifier 50 to show that this was a bilateral procedure.
The insurance company is denying it, stating that the modifier is not correct. They are stating that we only have the left breast cancer so it should be an LT modifier only. I explained to them that the mastectomy was done on both breasts, which is why we used the 50 modifier. Additionally, they are not recognizing ICD-10 code Z40.01. I even sent a dispute with information and research with my level 1 dispute, and it was upheld. Also, did we do the right thing by using the 50 modifier?
AAPC Form Participant
Answer: There are different issues creating the denial here. The first, and most likely, reason is that many payers do not recognize modifier 50 (Bilateral procedure) for bilateral mastectomies and want the claim on two separate lines using LT (Left side) and RT (Right side).
You should try resubmitting the claim using the following:
Line 1: 19303 (Mastectomy, simple, complete)-LT, C50.912 (Malignant neoplasm of unspecified site of left female breast)
Line 2: 19303-RT, Z40.01(Encounter for prophylactic removal of breast), C50.911 (Malignant neoplasm of unspecified site of right female breast)
The second issue is your payer not recognizing Z40.01, despite the fact it is a legitimate ICD-10-CM code and the primary reason for the removal of the right breast. To rectify this, you could try leaving out the Z40.01 on the right breast line. But you should clarify with your payer first and provide whatever documentation they may require that supports medical necessity for the prophylactic removal.
Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
