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ICD-10 Codes for Plastic Surgery Clinics: Codes You Should Know and Mistakes to Avoid

By: Nextech | February 23rd, 2015

ICD-10 Codes for Plastic Surgery Clinics: Codes You Should Know and Mistakes to Avoid Blog Feature

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Medical coding is a shared language that allows clinicians, insurers, and government agencies to effectively share information about a patient’s health. The coders in a plastic surgery practice use codes to communicate diagnoses and treatment procedures to payers.

What’s the Difference Between ICD-10 and CPT Codes?

Diagnoses are classified with ICD-10 codes, while procedures are classified using CPT codes. ICD-10 stands for the 10th revision of the International Classification of Diseases, created and maintained by the World Health Organization.

In plastic surgery, ICD-10 codes can vary based on whether the underlying cause of the diagnosis is medical or cosmetic. This is an important distinction, as many health insurers will not cover purely cosmetic procedures.

Codes are further divided into ICD-10-CM, for clinic and outpatient settings, and ICD-10-PCS, for hospital and inpatient settings.

Changes to ICD-10 for 2025

The World Health Organization updates its list of codes annually. The 2025 changes to the ICD-10 took effect Oct. 1, 2024.

This year’s changes included:

  • 252 new CM codes
  • 36 deleted CM codes
  • 13 revised CM code descriptions

ICD-10 Codes Commonly Used in Plastic Surgery

Here are some common codes every medical coder in a plastic surgery practice should be familiar with. It’s important coders know the designation for both cosmetic and medically necessary procedures.

This list is representative only and not intended to be comprehensive.

 

ICD-10 Codes for Cosmetic Breast Disorders

ICD-10 code N64.89 is applicable to multiple non-malignant breast disorders, including:

  • N64.89: Asymmetry of left and right breast
  • N64.89: Pendulous breasts
  • N64.89: Radial scar of breast
  • N64.89: Breast hematoma
  • N64.89: Breast duct occlusion

 

ICD-10 Codes for Breast Reduction

Breast reduction procedures are used to treat a diagnosis of breast hypertrophy. The applicable ICD-10 code depends on the symptoms the procedure is intended to address.

The ICD-10 code for breast reduction depends on the symptoms of breast hypertrophy the surgeon is using to justify the procedure.

  • N64.1: Fat necrosis of the breast
  • N64.4: Breast reduction to resolve chronic breast pain
  • M54.89: Breast reduction to resolve unspecified back pain
  • M95.4: Breast reduction to resolve shoulder grooving from bra straps
  • R20.0: Breast reduction to resolve brachial plexus compression syndrome
  • Z41.1: Breast reduction for cosmetic purposes

 

ICD-10 Codes for Breast Augmentation

The ICD-10 code for a cosmetic breast augmentation is Z41.1.

ICD-10 code Z98.82 is often used in conjunction with other codes to note the presence of a breast implant.

 

ICD-10 Codes for Tummy Tucks (Abdominoplasty)

Abdominoplasty can refer to surgery performed on the skin, underlying tissue, or rectus abdominis muscles.

  • 0HB7XZZ: Excision of abdomen skin, external approach
  • 0J080ZZ: Alteration of abdomen subcutaneous tissue and fascia, open approach
  • 0WBF0ZZ: Excision of abdominal wall, open approach
  • 0J083ZZ: Alteration of abdomen subcutaneous tissue and fascia, percutaneous approach
  • M62.00: Diastasis recti separation of muscle, unspecified site
  • O71.89: Diastasis recti due to other specified obstetric trauma

 

ICD-10 Codes for Cosmetic Surgery

Cosmetic surgeries in general fall under the primary category Z (encounters for other specified healthcare), a catch-all category for medical encounters with a stated purpose not found elsewhere in ICD-10.

The secondary category is 41 (encounter for procedures for purposes other than remedying health state).

Though these surgeries are rarely covered by insurance, precise coding is crucial to maintaining an accurate patient health record.

  • Z41.1: Encounter for cosmetic surgery
  • Z41.2: Encounter for routine and ritual male circumcision
  • Z41.3: Encounter for ear piercing
  • Z41.8: Encounter for other procedures for purposes other than remedying health state
  • Z41.9: Encounter for procedure for purposes other than remedying health state, unspecified

 

ICD-10 Codes for Liposuction

Liposuction is one procedure in which the ICD-10 code depends on whether fat removal is medically necessary or cosmetic.

If panniculitis affects just one part of the body, coders may opt to use a more specific code.

  • M79.3: Panniculitis, unspecified
  • Z41.1: Cosmetic fat removal

 

 

ICD-10 Codes for Burns

Plastic surgery to treat burn injuries is coded based on where the injury is located and how much of the body is affected.

  • T20: Burn and corrosion of head, face, and neck
  • T21: Burn and corrosion of trunk
  • T22: Burn and corrosion of shoulder and upper limb
  • T23: Burn and corrosion of wrist and hand
  • T24: Burn and corrosion of lower limb
  • T25: Burn and corrosion of ankle and foot
  • T31.0: Burns involving less than 10% of body surface
  • T31.1: Burns involving 10%-19% of body surface
  • T31.2: Burns involving 20%-29% of body surface

 

ICD-10 Codes for Cleft Lip and Cleft Palate

Cleft lip and cleft palate ICD-10 codes are very specific, based on where the disorder is located.

  • Q35: Cleft palate
  • Q35.1: Cleft hard palate
  • Q35.3: Cleft soft palate
  • Q35.5: Cleft hard palate with cleft soft palate
  • Q35.7: Cleft uvula
  • Q35.9: Cleft palate, unspecified
  • Q36: Cleft lip
  • Q36.0: Cleft lip, bilateral
  • Q36.1: Cleft lip, median
  • Q36.9: Cleft lip, unilateral
  • Q37: Cleft palate with cleft lip
  • Q37.0: Cleft hard palate with bilateral cleft lip
  • Q37.1: Cleft hard palate with unilateral cleft lip
  • Q37.2: Cleft soft palate with bilateral cleft lip
  • Q37.3: Cleft soft palate with unilateral cleft lip
  • Q37.4: Cleft hard and soft palate with bilateral cleft lip
  • Q37.5: Cleft hard and soft palate with unilateral cleft lip
  • Q37.8: Unspecified cleft palate with bilateral cleft lip
  • Q37.9: Unspecified cleft palate with unilateral cleft lip

 

ICD-10 Codes for Rhinoplasty

Rhinoplasty ICD-10 codes look at what part of the nose is being altered and why.

  • C30: Malignant neoplasm of the nasal cavity
  • C43.31: Malignant melanoma of the nose
  • C44.311: Basal cell carcinoma of the skin of the nose
  • C44.321: Squamous cell carcinoma of the skin of the nose
  • J32: Chronic sinusitis
  • J34.2: Deviated nasal septum
  • Q67.0: Congenital facial asymmetry
  • R09.81: Nasal congestion
  • S02.2XX: Fracture of nasal bones

 

Common Coding Errors for Plastic Surgery Practices to Avoid

Coding errors have a direct impact on a plastic surgery practice’s bottom line. Incorrect coding is one of the primary reasons insurers deny claims. This can lead to costly delays in reimbursement, slowing the revenue cycle.

Avoid these common mistakes to keep claims moving smoothly:

1. Allowing staff training to lapse

Advancing technology, new techniques, and the changing regulatory landscape all impact how diagnoses are coded — and how your practice gets paid. The ICD-10 is updated annually. It’s important your staff’s training stays up to date. 

A practice that invests in training sends a message to employees that it cares about them and their careers. These are important factors in employee satisfaction and retention.

2. Not being specific in coding

Many ICD-10 codes have variations based on the underlying cause of the diagnosis, the specific location of the surgery, and other nuances.

Though most of these also include a catch-all “unspecified” code, it’s better to code with as much specificity as possible. This increases the likelihood of clean claims, as payers can clearly understand the patient’s condition.

Specificity in the EHR gives your patient’s future providers a clearer picture of their health history, and aids in compilation of accurate public health statistics.

This is not an issue coders can address by themselves. They are using the information the clinician entered in the EHR — if it’s not specific, the code won’t be, either.

Establish practices that emphasize complete documentation and clear communication between clinical and administrative staff. Automated charting technology can streamline the process.

3. Consolidating diagnoses and services

When multiple decisions are made or services are performed in the same visit, it can lead to another common and easily avoidable coding error — lumping the entire visit under one code.

A simple example is an exam with abnormal findings. The exam, the diagnosis, any treatment delivered, and any follow-up prescribed must all be coded separately in the claim.

Clinicians can help with this by being very specific as they enter information into the plastic surgery EHR, noting everything that occurred in the visit.

4. Misusing modifiers

Modifiers are codes that append to standard codes to indicate special circumstances, such as two appointments in the same day for different reasons. They should be used with discretion.

Be prepared to be challenged on the use of modifiers, and be sure you have the documentation to justify them. When possible, avoid modifiers and use specific ICD-10 codes instead.

5. Not taking advantage of automation

Your plastic surgery EHR can be one of your greatest coding tools. A robust, specialty-specific EHR relieves the burden on both clinician and coder, while documenting the smallest details.

During the patient visit, automated tools prefill information, allowing clinicians to spend more face time with their patient than their screen. As the clinician enters their notes, prompts ensure coders will have the specificity they need.

Besides facilitating communication with clinic staff, the EHR helps coders perform their tasks more efficiently.

A plastic surgery-specific practice management system prioritizes the codes relevant to the specialty, making it easy for staff to find and verify the codes they need without wading through chapters on eye diseases or respiratory failure.

The tool’s built-in checks ensure diagnoses and services are coded correctly and that nothing was improperly consolidated.

Improve Coding Efficiency at Your Plastic Surgery Practice

Nextech’s plastic surgery-specific technology platform creates and supports an efficient workflow between clinical and billing staff.

Advanced automation reduces the risk of manual errors. The system includes automatic checks and validation and is always up to date with the latest guidelines.

In addition, you’ll enjoy less paperwork, better patient engagement, and data you can use to make strategic business decisions.

Efficient coding boosts your clinic’s productivity, reduces claims denials, and improves your revenue cycle management. Schedule a demo to see what Nextech can do for you.