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 New Mexico (BCBSNM) 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 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.
Refer to BCBSNM Medical Policy Gender Assignment Surgery and Gender Reassignment Surgery with Related Services SUR717.001 for more information.
Checking eligibility and/or benefit information and/or obtaining prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. If you have any questions, call the number on the member's ID card.
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