How is Plastic Surgery Billing & Coding Different

November 4, 2021
by Admin

The words “plastic surgery” often can conjure thoughts of celebrities attempting to preserve their youth. But plastic surgery isn’t all about “cosmetic” surgery. Not only can a number of traditionally “cosmetic procedures” be covered by insurance (i.e., breast reductions, rhinoplasties, blepharoplasties, panniculectomies, etc.), but many plastic surgeons serve patients seeking strictly medically necessary procedures such as hand reconstruction, wound care or breast reconstruction post mastectomy as well as other deformities, trauma, infection, or diseases.

Depending on the reason, plastic surgery can be covered by insurance. The key here is whether the surgery is medically necessary or elective. Knowing the difference and coding the procedure correctly is the difference between insurance approval or denial. ?

If your patient meets the right criteria, the procedure should be covered by insurance. If not, and your team knows the difference up front, you can better identify a sales opportunity as well!

When is Plastic Surgery Covered by Insurance?

There are basically two camps in plastic surgery procedures: aesthetic (aka cosmetic) or reconstructive.

Aesthetic or cosmetic surgery is typically elective. These are the surgeries people elect to pay for in order to improve appearance and/or boost confidence without a medically necessary cause. Think “I don’t love the curve of my nose” versus “I just took a baseball to the face and I can’t breath out of my left nostril.” Both nose jobs, or rhinoplasty, here will address the aesthetics/look, but one has a bit more of an acute/pressing cause. Insurance companies cause this functional impairment…AKA “we’ll pay for it now”

Reconstructive plastic surgery is conducted on an abnormal or damaged body part to improve functionality because of a problem. This might include cancer or tumor removal, burn reconstructive surgery, rhinoplasty to improve breathing issues (see above reference to baseball), etc.

THEN, of course, there is a grey area. Some plastic surgeries that are considered cosmetic, such as eyelid surgery or breast reduction, can be covered by insurance if patients meet the right criteria. This is the crux of the plastic surgery struggle…knowing where the line is.

Coding is extremely nuanced for plastic surgery operations. Procedures like breast reconstruction and hand reconstruction are particularly difficult to code whereas those grey area procedures like breast reductions, rhinoplasties, blepharoplasties are extremely difficult to get covered. Then there are the burgeoning procedure segments like migraine surgery, gender-affirming surgery, use of ADMs in integumentary system procedures…which can be extremely difficult to get covered because they are considered “experimental” by insurance companies…who are patently ignorant by choice.

Plastic surgery is heavily scrutinized because many procedures can “go either way.” Bottom line—knowing the difference between cosmetic and reconstructive is VERY important.

Customer Service is ? 

This is the sales end of medicine people. Patients are paying top dollar for something they may or may not “need” and they expect the service to match the sticker price. This includes helping them get coverage when appropriate. That means knowing how to guide them and set expectations appropriately in the pre-authorization process…not being a yes man/woman. This also means being top tier in claims rejections/denials/AR processes…because no matter what the knuckleheads do to not pay you…guess what their customer service team is going to tell your patient? You guessed it! That you “billed it wrong.” Make sure you have a billing pitbull to handle that BS and a great customer service team to explain to your patients what the real issue is.

Even if your practice knows that a procedure won’t be covered by insurance, keep communication with patients warm. It’s important to assure them that you will make your best efforts to get the procedure covered.  Who knows, you may help them through the journey so well, they decide to pay out of pocket when their non-covered procedure is denied.

Quality customer service and open communication will keep patients ? and help you drive sales ?.

Understanding Ancillary Billing Structures

Knowing the professional fees is one thing. What about incident-to billing for mid-levels? What about anesthesia billing for that team in you Ambulatory Surgery Center (ASC)? What about your ASC? Can you bill for out-of-network procedures?

There’s nuance in the nuance here folks. Not only the above, but what about the financial transactions in the billing system? You’re collecting deposits up front for cosmetic surgeries. You’re collecting at time of service for fee-for-service procedures like injectables and/or retail and/or skincare services in your medspa. It’s crucial to keep your insurance-paid and self-paid services clear and segregated in your financial data sets. Recognize where the credits go and avoid, for example, assigning sending a statement to Jane Doe for the Botox charge in her account because the front desk forgot to apply a payment. What if John open’s that bill and doesn’t know Jane was in the office getting a half grand worth of face-pump…now we have a real issue.

Billing is hard. Plastic surgery billing and coding is harder! Sometimes it’s best to just call in the experts. Contact Auctus Group. We can help.

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