Plastic surgery covers a wide range of corrective procedures. These procedures are by no means only for cosmetic purposes. Injuries from accidents, trauma, burns, and previous surgeries for diseases such as cancer demand medical necessity for plastic surgery.
This is why plastic surgery medical billing expertise plays a vital role in the success of any plastic surgery practice.
Understanding each procedure, medical necessity, slight variations for similar surgeries, wound measurements, donor sites, and a variety of different factors determines correct coding, payment, and risk factors for audits.
This article covers the complexities of plastic surgery medical billing, including CPT coding, medical necessity, insurance authorization, operative note review, documentation requirements, and specialty-specific billing challenges.
Plastic Surgery Billing and Insurance Refund Demands
We see a great number of insurance refund demands for incorrect procedure codes, non-supporting diagnoses, and unsupported medical records. Plastic surgery billing is more complex because it does not have a set CPT code to bill from. This is what most billers are used to doing. Most billers work with sets of service codes related to a single specialty. Plastic surgery can pull from thousands of CPT codes. They will be from the Integumentary System, Musculoskeletal & Craniofacial section, and Anatomical & Systemic issues.
Plastic Surgery Coding and Billing Audits
A plastic surgery biller must be an auditor as well. They will need to read each operative note, dissect each step of the procedure to identify the service code that represents the work done. Billing out claims with codes doctors assign without proper research will lead to claim rejection, underpayment, and payment retraction.
Plastic Surgery Claims: Questions to Ask Before Billing Surgery Claims
Before billing surgery claims, ask these questions:
- Has the need for surgery been clearly identified in examination notes prior to scheduling surgery?
- Is an insurance authorization on file for planned surgery?
- Does the authorization cover a range of service codes instead of a single CPT code? Keep in mind the scope of a procedure often changes in the operating room.
- Is the place of service for surgery covered by the authorization, such as office, outpatient surgery center, or hospital?
- In addition to authorization, does the patient’s condition meet all coverage requirements for the surgery?
- Will the surgery demand a planned or unplanned return to the operating room? Does the authorization cover add-on services?
Plastic Surgery Billing Across Different Specialties
Complexity for plastic surgery billing increases with different specialty doctors doing these surgeries, such as Dermatologists, Ophthalmologists, Hand surgeons, and many other specialists, including, of course, plastic surgeons. Each specialist’s documentation may vary, and applying a blanket rule for Plastic surgery billing may not work.
Dermatology and Plastic Surgery Billing
A dermatologist may want to bill for excising a growth and subsequent tissue transfer. For this case, medical need for excision must be clearly defined with exact millimeter or centimeter measurement of the surgical wound and area measurement of the tissue transfer from donor site. These two measurements will most likely not be the same.
Ophthalmology and Blepharoplasty Billing
An Ophthalmologist may need to do upper and lower lid Blepharoplasty, but the patient’s condition may support medical necessity of the upper lid surgery only. In this case, patients will have to pay out-of-pocket for lower lid surgery. Also, prerequisites for even medically necessary Blepharoplasty may vary according to individual insurance plans. The biller will need to ensure prerequisites for testing and lifestyle conditions due to illness are clearly documented.
Hand Surgery and Workers’ Compensation Billing
Hand surgeons may work with many different Workman Compensation programs, which is a battle. Even after establishing medical necessity and satisfying prerequisites, it is still a battle to get claims paid. The complexity of Plastic coding increases the risk of non-payment.
Breast Cancer Reconstruction and Plastic Surgery Billing
A plastic surgeon who is caring for breast cancer patients may need to do multiple surgeries. The biller must determine which CPT code best represents these surgeries. Service codes will vary depending on whether the surgery is for reconstruction, repositioning of an implant, taking out an implant, and much more
Final Words
Accurate plastic surgery medical billing requires careful attention to coding, medical necessity, documentation, authorization, and the specific requirements of each procedure and specialty. With the complexity of plastic surgery coding, proper review of operative notes and supporting records is essential to help prevent claim rejection, underpayment, and payment retraction.
If you need help with plastic surgery billing services, FC Billing can help. Our team can assist with accurate coding, claims submission, documentation review, and billing processes to help your practice improve reimbursement and reduce billing issues.
