29.2.35.13 Reconstructive and Cosmetic ProceduresThe CSHCN Services Program may reimburse specific reconstructive and cosmetic procedures that meet the following definitions:
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• Excision and destruction of a benign lesion, cyst, or lipoma are benefits only when the claim documentation indicates that the lesion is any of the following:
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• To include documentation on the claim form, use modifier KX to indicate the requirement specified above has been met. Excision and destruction of multiple lesions, cysts, or lipomas may be reimbursed according to the multiple surgery payment guidelines. Initial or follow-up visits billed in addition to a lesion excision or destruction for the same diagnosis are subject to global surgery payment criteria. The CSHCN Services Program will not reimburse the alteration of a natural, undamaged, or unimpaired body part. Authorization Requirements Procedures performed as part of cleft/craniofacial surgery require prior authorization and specialty team approval. Refer to: Section 4.3, "Prior Authorizations" for detailed information about prior authorization requirements. Appendix B, "CSHCN Services Program Prior Authorization Request for Inpatient Surgery-For Surgeons Only," on page B-72 and "CSHCN Services Program Prior Authorization and Authorization Request for Outpatient Surgery-For Outpatient Facilities and Surgeons," on page B-75. Noncovered Services The following procedure codes are not reimbursed for surgery, assistant surgeon, or ambulatory surgical center components:
Services Requiring Medical Review When billed, the following procedure codes will be suspended for medical review:
Procedure code 17003 is denied if billed on the same date of service by the same provider as 17004. Reduction Mammoplasty Reduction mammoplasties to equalize breast size are considered cosmetic and are not benefits of the CSHCN Services Program. Procedure code 19318 requires prior authorization for surgery and assistant surgery and may only be authorized when documentation supports the medical necessity for reduction mammoplasty. Requests that do not contain the required information are considered incomplete and are denied. Surgeons are required to include the following information in their letter of medical necessity requesting prior authorization:
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• All of the above must be submitted under the requesting surgeon's signature. Requests must be sent to the CSHCN Services Program medical director. Mail prior authorization requests for reduction mammoplasty for clients to:
Texas Medicaid & Healthcare Partnership Breast Reconstruction Breast reconstruction may be completed as multiple, staged procedures (e.g., tissue expansion followed by implants, nipple, or areola reconstruction) using either saline or silicone implants or tissue transfers such as transverse rectus abdominis myocutaneous (TRAM) flaps, latissimus dorsi flaps, or gluteal flaps. Breast reconstruction may be reimbursed as a surgery or assistant surgery for male and female clients with the following procedure codes:
Procedure code 19350 is denied if billed on the same date of service by the same provider as procedure code 19318. Procedure code 19367 is denied if billed on the same date of service by the same provider as procedure code 19368. Breast reconstruction following a medically necessary mastectomy is restricted to the following diagnosis codes:
An external breast prosthesis or surgery on the unaffected breast to achieve symmetry is not a benefit of the CSHCN Services Program. Surgical intervention of complications following breast reconstruction may be reimbursed with procedure codes 19370, 19371, and 19380. Procedure codes 19370 and 19380 are denied if billed on the same date of service by the same provider as procedure code 19342. Procedure code 19370 is denied if billed on the same date of service by the same provider as procedure code 19371. |
Reconstructive surgery. Surgery performed on structures of the body for the purpose of improving or restoring bodily functions or correcting significant deformity resulting from disease, trauma, or previous therapeutic process, or congenital or developmental anomalies.
