Plastic surgery billing is a tale of two practices: the reconstructive work that insurance pays, and the cosmetic work that patients pay out of pocket. The line between them isn't always obvious, and payers know it — which is why reconstructive plastic surgery claims get scrutinized heavily.
If you're working through these issues, our specialty billing services can help you address them systematically.
Insurance covers surgery to correct a functional impairment or a condition resulting from disease, trauma, or congenital abnormality. Cosmetic surgery, performed solely to improve appearance without a functional basis, is not covered. The same procedure can be reconstructive or cosmetic depending on the clinical indication.
Rhinoplasty for a deviated septum causing breathing obstruction — reconstructive. Rhinoplasty to change the shape of the nose — cosmetic. Blepharoplasty causing ptosis that obstructs the visual field — reconstructive. Blepharoplasty for baggy eyelids without functional impairment — cosmetic. The documentation has to make this distinction explicit.
Breast reconstruction following mastectomy is federally mandated to be covered by the Women's Health and Cancer Rights Act. This includes reconstruction of the affected breast, surgery to achieve symmetry of the opposite breast, and prostheses and physical complications. The WHCRA applies to all group health plans that cover mastectomy.
Bill reconstruction using CPT codes for the specific technique: 19340–19342 for implant-based reconstruction, 19357 for tissue expander, 19361–19369 for flap procedures (TRAM, DIEP, etc.). Each technique has specific documentation requirements around the type of reconstruction, the mastectomy that preceded it, and the reconstruction plan.
Excision codes differ based on whether the lesion is benign (11400–11471) or malignant (11600–11646). The distinction requires a pathology result. You can code based on clinical impression at the time of service, but if pathology comes back different, you may need to recode. Build a workflow to reconcile pathology results with billed codes within your timely filing window.
Size matters for excision coding — the code is selected based on the excised diameter including margins. Document the lesion size AND the total excision size including margins. Not just one or the other.
Plastic surgeons often repair complex wounds. The repair codes (12001–13160) are stratified by type (simple, intermediate, complex) and length in centimeters. Lengths of repairs of the same complexity can be added together across similar anatomic areas. Don't bill each laceration separately when they can be combined — and don't combine lacerations of different repair types or anatomically distinct regions.
Local flaps (14000–14302) and free flaps have their own codes. The flap size is measured as the area of primary and secondary defects, not just the flap itself. Documentation needs the dimensions of both.
Cosmetic procedures are non-covered and patient-pay. The billing implications: you don't submit to insurance (doing so for cosmetic procedures is fraud), you collect from the patient directly, and you don't need to accept Medicare assignment rates. Your practice sets the price.
Financial counseling before cosmetic procedures is essential. Patients need a clear understanding of the cost, what's included in the surgical fee versus anesthesia versus facility, and your collection policy. Practices that handle this poorly end up in payment disputes that are hard to resolve after the service is provided.
Most plastic surgery procedures have 90-day global periods. Post-operative visits within that period are included in the surgical fee. But if a complication arises requiring a return to the OR, a new global period may start. Use modifier -78 for returns to the OR for complications of the original procedure. Use modifier -79 for procedures unrelated to the original surgery during the global period.
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