April 29, 2022
The American Medical Association (AMA) recently updated their guidance for the correct Current Procedural Terminology (CPT®) codes to use when filing claims for breast removal and breast augmentation as part of gender reassignment surgeries. Blue Cross and Blue Shield of Illinois (BCBSIL) has updated its system to align with AMA and American Academy of Professional Coders (AAPC) billing guidance, as summarized below.
What’s New
For gender affirming breast reduction and/or removal for transgender male and non-binary members, the AMA and AAPC guidance is to use CPT code 19318 for breast reduction/reduction mammaplasty. Claims for gender affirming breast reduction and/or removal for transgender male and non-binary members should not be coded with 19303 for complete mastectomy +19350 for nipple/areola reconstruction.
Background
The AMA recommends the use of CPT code 19303 for the treatment or prevention of breast cancer. It recommends CPT code 19318 for reduction mammaplasty when breast tissue is removed for breast-size reduction and not for treatment or prevention of breast cancer.
The AAPC does not recommend the use of CPT code 19350 for nipple reconstruction in transmasculine gender reassignment. AAPC advises that CPT code 19318 may be used to reflect reshaping of the nipple for cosmetic purposes.
BCBSIL Resources
Refer to BCBSIL Medical Policy SUR717.001 - Gender Assignment Surgery and Gender Reassignment Surgery with Related Services for more information. Although medical policies can be used as a guide, providers serving HMO members should refer to the HMO Scope of Benefits in the BCBSIL Provider Manual.
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BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. Providers are instructed to exercise their own clinical judgment based on each individual patient’s health care needs. The fact that a service or treatment is described in a medical policy is not a guarantee that the service or treatment is a covered benefit under a health benefit plan. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. Members should contact the customer service number on their member ID card for more specific coverage information.