Practice Management Alert

Question: When coding a mastectomy for gynecomastia in a male, what CPT code should I use? I would have used 19300 but the nurse says not to use that code because payers deny it for cosmetic purposes.

Pennsylvania Subscriber

Answer: The code for male mastectomy for gynecomastia is 19300 (Mastectomy for gynecomastia). You cannot change the coding simply because the payer considers the service to be cosmetic.

Good practice: For procedures like this, it is best to check with your payers in advance to see if they have any payment guidelines related to the service. Many payers consider mastectomy for gynecomastia alone to be cosmetic, just as they would consider a rhinoplasty or similar procedure to be cosmetic. If there are other factors (functional limitations, pain, etc), some payers will consider paying for the mastectomy but it is very important that information is included in the op note and those additional diagnoses are included on the claim.

The key is checking with the insurer in advance and finding out what their rules are. Your practice signed a contract with the payer agreeing to follow their rules. Checking to see what those rules are in advance is the key to good patient relations as well as appropriate reimbursement.