Blue Cross and Blue Shield of Kansas reviewed the following services and noted that additional clarification was needed to better assist providers for correct billing to BCBSKS.
Tympanoplasty, also called eardrum repair, refers to surgery performed to reconstruct a perforated tympanic membrane (eardrum) or the small bones of the middle ear. Tympanic membrane grafting may be required. If grafting is needed, providers should code using CPT 69620 when using live tissue and use CPT code 69610 when performed without live tissue.
Code 69610 is repair of a tympanic membrane perforation by applying chemical cautery to the edges, freshening the edges, and then applying a paper patch to allow for ingrowth of tympanic membrane beneath the patch.
CPT code 69620 is identified as myringoplasty and requires a live tissue graft that is a plug or flattened graft of fat and /or fascia. The claim will need to be submitted with an operative report in order for us to determine if a live tissue graft was used.
Code 69631, tympanoplasty, wherein tympano indicates middle ear space, not just the tympanic membrane and requires the elevation of a tympanomeatal flap, that is the ear canal skin is elevated.
SURGICAL TREATMENT OF GYNECOMASTIA
Gynecomastia refers to the benign enlargement of the male breast, due to increased adipose tissue, glandular tissue, fibrous tissue, or a combination of all three.
Gynecomastia may be associated with any of the following:
1. Underlying hormonal disorders, e.g., condition causing either estrogen excess or testosterone deficiency such as liver disease or endocrine disorders;
2. Side effects of certain drugs;
3. Associated with obesity;
4. Related to specific age groups, e.g.;
a. Neonatal gynecomastia, related to action of maternal or placental estrogens,
b. Adolescent gynecomastia that consists of transient, breast enlargement, which may be tender,
c. Gynecomastia of aging, related to the decreasing levels of testosterone and relative estrogen excess.
Treatment of gynecomastia involves consideration of the cause. For example, treatment of the underlying hormonal disorder, cessation of drug therapy, or weight loss may be effective therapies. Adolescent gynecomastia may resolve with time. No functional impairment is associated with gynecomastia.
Providers performing mastectomy for gynecomastia should bill using CPT code 19300. The following guidelines apply for this service:
- Mastectomy as a treatment of gynecomastia is considered cosmetic due to the lack of a functional impairment. A Notice of Personal Financial Obligation is not required.
- If diagnosis of gynecomastia is prior to surgery and is in the office records, it is considered non-covered. A Notice of Personal Financial Obligation is not required.
- If diagnosis of gynecomastia and the physician notes it is not cosmetic and the surgery is for painful symptoms, it is considered not medically necessary.
- If diagnosis is painful mass and a determination of cancer is needed, it is considered not medically necessary. It is recommended that a mammography or fine needle aspiration be done to determine cancer.
Reminder: Not Medically Necessary Services
Contracting Providers shall notify the patient when services are considered not medical necessary and may not be covered under the member’s contract. Services determined not medically necessary will be denied as a provider write-off unless the provider obtains a Notice of Personal Financial Obligation (NOPFO) signed by the patient. If the provider obtains a NOPFO, you do not need to actually submit the NOPFO with the claim. Providers can append modifier GA to the applicable CPT code(s) and submit the claim electronically. Modifiers should immediately follow the procedure code, with no space between. The waiver is retained in the patient's file. By obtaining a signed NOPFO before the services are provided, the services deemed not medically necessary will be denied as the patient’s responsibility.