Gynecomastia

Question:

A 24-year-old male is seen in our office for gynecomastia. My physician did a bilateral resection of the glandular component and liposuction of the fatty components of his defect. I am new to coding for plastic surgery and not sure how to code this. Can you help?

Answer:

Of course. The CPT code reported is 19300-50 (Mastectomy for gynecomastia). Modifier 50 is used when the procedure is performed bilaterally. The diagnosis code to report is N62 (Hypertrophy of the breast).