What You Need To Know About Plastic Surgery Billing
Many think of plastic surgery procedures, such as a tummy tuck or nose job, as fully cosmetic. However, reconstructive surgery procedures can help patients correct health issues, including difficulty breathing, shoulder pain, and even cancer.
Because insurance coverage may deem your services and surgical procedures as cosmetic or reconstructive, it’s important to understand plastic surgery billing and coding for multiple procedures at your practice. By doing so, you can determine medical necessity for patients, provide good-faith estimates, and reduce denials from the insurance company.
Understanding the Unique Challenges of Plastic Surgery Billing
Billing and coding can be incredibly complicated for plastic surgery practices. Is that procedure the patient wants cosmetic or medically necessary? Will the insurance company cover it, and what about Medicaid? What happens if you’re an out-of-network surgeon working at an in-network facility?
It’s important to find the answers because these factors can affect your practice’s revenue cycle and bottom line. Below, we discuss some common challenges you’ll need to overcome with billing and coding at your practice.
Diverse Range of Procedures
When coding and billing for emergency care, post-stabilization care, and other plastic surgery services, you may think each procedure has only one code. However, this isn’t so. For instance, coding services may use a different code depending on whether a patient’s insurance company deems the procedure cosmetic or reconstructive.
Because of this, many plastic surgeons seeking prior authorization accidentally submit the wrong code to insurance or Medicaid services. This can cause the insurance company to deny prior authorization.
Having to contend with medical billing for multiple procedures causes frustration for self-pay patients as well. You should always aim to provide a good-faith estimate and ensure you make no mistakes on a patient’s bill. Making mistakes on a bill could affect your proposed payment amount and overall revenue cycle.
Most insurance companies will not reimburse you for services it deems cosmetic. To avoid denials, you must provide an appropriate ICD-10-CM modifier that demonstrates medical necessity. If you cannot do this, patients will have to self-pay for your services.
If you think a service is medically necessary, you can file an appeal and undergo an arbitration process. It may take a single business day to make an appeal, but expect the insurance company to get back to you several business days later.
If a surgery is, in fact, medically necessary, you may need to get prior authorization to perform the service. A patient must also know whether your practice is in or out of their network. If you’re an out-of-network provider, the patient’s insurance might not cover the payment amount of surgery. Patients may need to fund much, if not all of, their care if they seek surgery from out-of-network providers.
Compliance and Documentation
It is critical for your human services or coding services department to avoid coding and billing issues that could lead to legal problems and claim denials. One law you must be aware of is the No Surprises Act.
The No Surprises Act includes federal protections that have ended the majority of out-of-network bills for privately insured patients. These protections are focused on emergency and post-stabilization services, as well as non-emergency services provided by an out-of-network provider at an in-network facility.
In addition to the No Surprises Act, you may have to comply with state laws that prevent you from hitting patients with a surprise bill or administrative fee. For instance, your state’s laws may prohibit balance billing, which involves billing the patient for the difference between your charge and the amount paid by insurance.
Plastic surgeons and other healthcare providers must also provide a good-faith estimate to people who don’t have or don’t want to use their insurance coverage to pay for services.
Essential Plastic Surgery Billing Codes
There are many medical billing codes for plastic surgery procedures, and it would be impossible to go over all coding guidelines within the scope of this guide. Below, we aim to cover some of the most common plastic surgery diagnostic codes a provider may use for surgery procedures.
Billing and coding differ depending on whether a surgical procedure is considered cosmetic or reconstructive. Cosmetic procedures include those done to enhance appearance at a patient’s request. Reconstructive surgery, on the other hand, covers services that healthcare providers deem a medical necessity (including certain emergency services).
Rhinoplasty for the nasal tip (CPT code 30400) is primarily cosmetic, whereas primary rhinoplasty to reshape nasal bones (CPT 40410 and 30420) is considered medically necessary and, thus, reconstructive.
However, a rhinoplasty tip procedure may be considered reconstructive if all of the following are true:
- The patient has prolonged obstructed breathing due to tip drop.
- Photos clearly show tip drop as the cause of an anatomic mechanical nasal airway obstruction.
- Airway obstruction is causing serious symptoms, such as trouble breathing.
- Symptoms persist for four or more weeks despite treatment.
Breast surgery has several CPT codes depending on the services provided. The following are some common codes used for breast surgery:
- 19350: Breast reconstruction:
- 19316: Breast suspension
- 19318: Breast reduction
Liposuction is a procedure during which a plastic surgeon removes fat from the stomach, buttocks, arms, hips, or neck. For this surgery, use code 15877.
An abdominoplasty, also called a tummy tuck, is considered cosmetic and likely not covered by most health plans. Plastic surgeons should use code 15847.
A facelift, also called meloplasty or rhytidectomy, tightens and removes sagging skin on the face and neck. For the chin, cheek, and neck, use code 15828. For superficial musculoaponeurotic system (SMAS) flap surgery, use code 15829.
Blepharoplasty improves the appearance of drooping eyelids for patients. Use code 15822 (or 15823 if there is excessive skin weighing down the lid).
Codes for skin grafts and flap procedures range from 14000–14302. The code you use will depend on the type and size of the skin transfer, as well as the procedure’s complexity. You may also have to use a modifier to accurately reflect the procedure.
For certain surgical procedures deemed cosmetic by an insurance plan or Medicare and Medicaid, you can use the following ICD-10-CM codes to support medical necessity:
- N65.1: Disproportion of reconstructed breast
- Z42.1: Encounter for breast reconstruction following mastectomy
- J32.0: Chronic maxillary sinusitis
- J34.2: Deviated nasal septum
Learn How Weave Can Help You Simplify Billing and Coding for Patients
Plastic surgery billing can be incredibly complex, especially given the frequent changes made to CPT codes. Weave may not be able to figure out the coding part for you, but our software can certainly make the billing process far easier to handle.
Weave allows customers to securely store their card data and pay in your office with a simple tap, dip, or swipe of their phone. Customers can also easily access their bills online or take advantage of financing programs. Plus, 83% of practices that use Weave for billing get paid faster. It’s a win-win for everyone.
To find out more about how Weave can transform plastic surgery billing from a headache to a breeze, book a free demo of our software today.
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Codes referenced in this article
5-digit CPT Codes
|Rhinoplasty, nasal tip (cosmetic)
|Rhinoplasty, nasal bones (reconstructive)
|Rhinoplasty, nasal reshaping (reconstructive)
|Abdominoplasty (tummy tuck)
|Facelift (chin, cheek, neck)
|Facelift (SMAS flap)
|Blepharoplasty (eyelid surgery)
|Blepharoplasty with excessive skin
|Disproportion of reconstructed breast
|Encounter for post-mastectomy reconstruction
|Chronic maxillary sinusitis
|Deviated nasal septum