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2012 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 8. Physician : 8.2 Services, Benefits, Limitations, and Prior Authorization : 8.2.43 Mastectomy and Breast Reconstruction : 8.2.43.1 Mastectomies

8.2.43.1
The following procedure codes for partial mastectomy, simple, subcutaneous, radical, and modified radical mastectomy are benefits of Texas Medicaid:
Procedure codes 19301 and 19302 may be reimbursed for services rendered to male or female clients of any age when the services are billed with an appropriate diagnosis code.
For clients with a diagnosis of cancer, procedure codes 19301 and 19302 may be reimbursed for more than 2 services rendered per lifetime.
Procedure codes 19303, 19304, 19305, 19306, and 19307 may be reimbursed for services rendered to male or female clients who are 18 years of age and older when the services are billed with an appropriate diagnosis code. Prior authorization is required for services rendered to clients who are 17 years of age and younger.
Procedure codes 19303, 19304, 19305, 19306, and 19307 are limited to 2 services per lifetime.
Mastectomy and breast reconstruction procedures may be reimbursed without prior authorization for services rendered to clients who are 18 years of age and older when the procedures meet the criteria outlined below and are billed with the following diagnosis codes:
*Diagnosis codes V103, V163, V4571, and V8401 may be billed only with breast reconstruction procedures and simple, subcutaneous, radical, and modified radical mastectomy procedures.
The physician must maintain documentation of medical necessity in the client’s medical record. Services are subject to retrospective review.

Texas Medicaid & Healthcare Partnership
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