Oncology & Hematology Coding Alert

Question: Medicaid is denying a claim for 19303 because the patient is male. They say that the code is gender specific to females. I don’t see anything in the guidelines that say this is so. How should this be documented?

AAPC Forum Participant

Answer: While you are correct in saying that nothing in the code descriptor or guidelines for 19303 (Mastectomy, simple, complete) is specific to female patients, the code may not be the correct one to describe the procedure your surgeon performed.

Without knowing the specifics of the scenario, it is hard to know why the claim was denied, though there are two possible explanations.

The first is that the procedure does not align with the diagnosis code you submitted. CPT^® code 19303 implies the patient has breast cancer, which means the procedure must match a male-specific C50.- (Malignant neoplasm of breast) ICD-10-CM code. This would be true for the other mastectomy codes, too — partial (19301-19302), complete (19303), radical (19305-19306), and modified radical (19307). CPT^® guidelines accompanying these codes tell you that these procedures “are performed either for treatment or prevention of breast cancer” with one important exception: 19300 (Mastectomy for gynecomastia).

Gynecomastia is a condition affecting males who are experiencing a hormone imbalance. When the female hormone, estrogen, exists in higher amounts in the male body than the male hormone, testosterone, the male can experience a growth in breast tissue. The condition, coded to N62 (Hypertrophy of breast), is not usually serious and generally only causes uneven lumps and tenderness. While the condition tends to resolve itself over time, occasionally a surgeon may decide to remove the tissue, which is when you would use 19300.

The second reason for the denial may be that your documentation did not support the medical necessity for the procedure. Even though “Medicare considers reduction mammaplasty reconstructive for gynecomastia,” and “mastectomy with nipple preservation or reduction mammoplasty is considered reconstructive and medically reasonable and necessary,” according to Medicare local coverage determination (LCD) L35090 (www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=35090), you may still need to justify the reason for this male mastectomy.

Fortunately, the LCD provides guidance for that. Simply put, your documentation needs to note that the patient is experiencing “pain or tenderness directly related to the breast tissue which has a clinically significant impact upon activities of daily living,” or “the excessive breast weight adversely affects the supporting structures of the shoulders, neck, and trunk,” per the LCD.

Private payer determinations may differ from this, however, so you will need to confirm with them to make sure their policies align with Medicare’s should the situation arise.