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.