Summary & Overview
HCPCS Level II M1280: Bilateral Mastectomy or History of Bilateral Mastectomy
HCPCS Level II code M1280 denotes documentation of women who have undergone a bilateral mastectomy, have a history of bilateral mastectomy, or have evidence of both right and left unilateral mastectomies. This designation matters nationally because it affects eligibility for reconstruction services, prosthetic devices, and related coverage determinations across multiple payers. Accurate use of the code supports consistent coverage decisions and streamlined claims processing for post-mastectomy care.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the code’s clinical context, the typical service settings where it applies, and which payers commonly manage claims tied to mastectomy history. The publication summarizes benchmark considerations and common billing practices, highlights policy implications for coverage of reconstruction and prosthetics, and outlines areas where payers may require documentation to support eligibility. Data not available in the input is noted where applicable.
Billing Code Overview
HCPCS Level II code M1280 describes coverage for women who have had a bilateral mastectomy, have a history of a bilateral mastectomy, or for whom there is evidence of a right and a left unilateral mastectomy. The code captures eligibility related to prior surgical breast removal on both sides and is used to document patient status for services tied to bilateral mastectomy history.
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Service type: Reconstruction- and prosthesis-related services associated with bilateral mastectomy status
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Typical site of service: Ambulatory surgical centers, hospital outpatient departments, physician offices, and durable medical equipment or prosthetics suppliers
Clinical & Coding Specifications
Clinical Context
A 52-year-old woman with a prior history of bilateral mastectomy for high-risk breast disease presents to a reconstructive surgery clinic for evaluation of mastectomy-related prosthetic fitting and potential revision surgery. The clinical workflow begins with review of prior operative reports confirming bilateral mastectomy, physical exam to assess chest wall contour, scar tissue, and implant status if reconstruction was performed, and discussion of prosthetic breast form options or surgical revision. Pre-procedure documentation includes date and type of original mastectomy (bilateral simple or modified radical), indication (prophylactic or therapeutic), relevant comorbidities such as diabetes or prior radiation, and informed consent. Typical visits include nursing intake, physician evaluation, measurement for external prosthesis or planning for secondary reconstructive procedures, potential ordering of imaging (chest wall ultrasound or MRI if implant concerns exist), and scheduling of prosthetic fitting or operative revision. Billing uses the HCPCS Level II code M1280 to denote women with bilateral mastectomy status when supplying post-mastectomy external breast prostheses or related supplies. Typical site of service is an outpatient surgical clinic, prosthetic/orthotic supplier office, or ambulatory surgery center depending on whether the encounter is non-surgical prosthetic fitting or operative intervention. Typical patient scenario: outpatient prosthetic consultation and fitting for external breast prosthesis after healed bilateral mastectomy scars, or preoperative planning visit for implant exchange or autologous reconstruction in a patient with prior bilateral mastectomy.
Coding Specifications
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