Plastic Surgery Billing Services
Reconstructive versus cosmetic, medical necessity documentation, global periods and prior authorization.
Plastic surgery is two businesses billed on one schedule. Reconstructive work goes to insurance, with prior authorization and documented medical necessity. Cosmetic work is paid by the patient and needs no payer at all. Submit one as the other and you get a denial. Do it repeatedly and you get an audit. Our plastic surgery billing services separate the two at intake.
Practices comparing plastic & reconstructive surgery billing services should ask how the biller documents functional impairment. Photographs, failed conservative treatment and a measured deficit are what actually get a reconstructive procedure approved.
Our Services
Reconstructive and Cosmetic Are Not the Same
Plastic surgery is detailed work, both in theatre and in the coding. Many billing services treat reconstructive and cosmetic as interchangeable. They are not, and that mistake ends in denials or silence from the payer.
We know which procedures insurance covers and which it does not. That means the claim goes out right, you charge the patient correctly, and the rest is our problem rather than yours.
What attributes are provided by our Medical Billing Services for Plastic Surgery?
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Comprehensive Verification
The line between reconstructive and cosmetic surgery decides who pays. So we do not send a claim until we have checked that the surgery is covered. That check at the start is what makes the rest of the claim cycle go smoothly.
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Swift Processing
Once the claim is out, the next thing that matters is how fast it is processed. That has been our focus for years, and it is why practices stay with us.
Subject Matter Experts (SMEs)
We list plastic surgery on its own for a reason. It is a complicated field to bill, and the problems in it are not obvious unless you have worked in it for a while.
Cost-Effectiveness
The main reason to outsource billing is simple: you collect more. That includes the money you used to lose to mistakes in preparing and filing claims. Count that back and outsourcing usually pays for itself, even after what the plastic surgery billing services company charges.
Procedure
Proficient expertise in medical coding and billing for Ambulatory Surgery Centers:
- Scar Revision
- Reconstruction Surgery
- Laceration Repair
- Post-mastectomy Surgery
- Breast Reconstruction Surgery
Reconstructive or cosmetic is the whole question
In plastic surgery the coding is rarely the difficult part. Establishing that the procedure is reconstructive, and proving it before the operation, is where the revenue is decided.
Documenting function, not appearance
A payer covers a procedure when it restores function or corrects a problem caused by disease, injury or a congenital condition. The record has to speak that language.
- For an upper eyelid procedure, the visual field testing and photographs showing the obstruction, not a note that the lids look heavy.
- For removal of excess abdominal skin, the documented rash or infection under the fold, how long it has been treated, and what treatment has failed.
- For breast reduction, the symptoms, their duration, the conservative treatment tried, and the measurements the payer's policy asks for.
Read the payer's own policy before the visit and write the note against it. Appealing afterwards with a record that was never built for the question rarely works.
Get the authorisation in writing, with the codes on it
Verbal approval from a call is not usable when the claim denies. The authorisation needs the procedure codes, the diagnosis, the site and the validity dates. If the operation changes in theatre, the authorisation no longer matches the claim and it has to be sorted out before billing rather than after.
Mixed cases
When a reconstructive procedure and a cosmetic one happen in the same session, the cosmetic part is the patient's responsibility and needs a signed estimate beforehand. The operative note has to separate the two clearly enough that a reviewer can see which theatre time and which supplies belong to which.
Collecting the cosmetic portion after the operation, without a signed estimate, is how these accounts become bad debt.
Global periods still apply
Reconstructive procedures carry the same global periods as any other surgery, and staged reconstruction is common in this specialty. Planned stages, unplanned returns and unrelated procedures each have their own modifier, and using the wrong one turns a payable second stage into a denial.
Plastic Surgery Credentialing and Hospital Privileges
Plastic surgery billing turns on one line: reconstructive or cosmetic. Credentialing decides which side you can work on. Reconstructive work is billed to insurance and nearly always needs prior authorization with documented medical necessity. Cosmetic work is paid by the patient and needs no payer contract at all. A practice doing both needs full payer enrollment for one half and a clean self-pay process for the other.
Hospital privileges are essential for reconstructive work, especially breast reconstruction, trauma and burns. Each facility privileges on its own cycle. Many payers also limit certain reconstructive procedures to board-certified plastic surgeons, so the board certification recorded at credentialing directly controls what you can bill.
We handle payer enrollment and privileging together. See our medical credentialing services.