Effective April 1st, 2019, MSP added a new fee code (61053) for bilateral breast construction for gender affirming surgery (male to female – MtF). They’ve also amended 61054, so that transgender patients now must meet the clinical criteria for FtM surgery.
Here are the details:
New Fee Code 61053 (Bilateral Breast Construction)
- 61053 is only applicable if you have prior approval for transgender services. Without approval, it isn’t eligible as a MSP benefit. Approval for surgery requires a medical assessment by qualified medical assessors who have recognized and demonstrable expertise in the treatment of gender dysphoria. It’s done through the PHSA.
- Your patient has to meet the clinical criteria for MtF surgery which are:
- Persistent, well-documented gender dysphoria
- Capacity to make a fully informed decision and to consent for treatment
- Age of majority
- If significant medical or mental concerns are present, they must be reasonably well-controlled
- Completed at least 18 months of feminizing hormone therapy (with the purpose to maximize breast growth in order to have better surgical results).
61054 Amendment (Bilateral Mastectomy)
- 61054 includes bilateral subcutaneous mastectomy, nipple-areolar reconstruction and chest wall reconstruction.
- (NEWLY AMENDED) In order to be MSP approved, transgender patients must meet the clinical criteria for FtM surgery which includes:
- Persistent, well-documented gender dysphoria
- Capacity to make a fully informed decision and to consent for treatment
- Age of majority
- If significant medical or mental concerns are present, they must be reasonably well-controlled
- Completed at least 18 months of hormone therapy
Extra Notes:
- Not billable in addition to 07498 (mastectomy, subcutaneous), 06157 (nipple-areolar reconstruction), and 61330, 61331, or 61332 (local tissue shifts, multiple).
- Otherwise subject to General Preamble rules for multiple surgery
If you have any questions about these fee codes or other MSP codes contact out billing team and leave us a detailed message.