Plastic surgery billing and reconstructive coverage
Plastic surgery billing starts with a clear benefit check. The federal Women's Health and Cancer Rights Act requires group plans that cover mastectomy to cover reconstruction, including procedures on the other breast to produce a symmetrical appearance. We also confirm which procedures the plan excludes as cosmetic and whether both the surgeon and the facility are in network through eligibility verification. For cosmetic-only cases, no insurance claim is filed and the patient's signed financial agreement governs.
Pre-determination for functional procedures
Upper eyelid blepharoplasty (15823) often needs visual field testing and photographs, while breast reduction (19318) is often reviewed against criteria such as symptoms and the amount of tissue removed. A pre-determination is not a promise of payment, so the final claim still needs documentation that matches the approved request.
Our authorization team submits the photos, measurements and treatment history that payer criteria ask for, and tracks the decision against the surgery date.
Coding staged and bilateral procedures
Staged reconstruction uses modifier 58, multiple procedures use 51, and bilateral procedures use 50 or RT/LT depending on payer rules. Multiple procedure reductions apply to secondary procedures, so the highest-valued procedure is listed first, and routine follow-up inside a global period is not billed separately. Our coding reviewers check modifier choice against each payer's policy before the claim goes out.
Mixed cosmetic and reconstructive cases
When cosmetic and reconstructive procedures happen in one session, charges must be split so only the reconstructive portion goes to the payer. Operating room and anesthesia time may also need to be allocated between the two, and the patient-pay portion should be agreed in writing before surgery so there are no surprises on the statement.
Plastic surgery billing services for deposits and AR
Cosmetic procedures are often paid in advance. Our plastic surgery billing services reconcile deposits and refunds against final charges through payment posting, while insurance balances on reconstructive cases are worked by payer and age. Patient balances follow clear statements and agreed payment plans, and a free billing assessment reviews how your current split cases are billed.
Plastic surgery billing: reconstructive versus cosmetic documentation
Plastic surgery medical billing turns on one distinction: reconstructive work that medical insurance covers versus cosmetic work the patient pays for. The documentation has to draw that line clearly — photographs, functional impairment notes and the prior authorization secured before surgery for the reconstructive cases. Our billing team verifies benefits to confirm what the plan covers, keeps the authorization on file for every covered procedure and bills self-pay cosmetic cases on a clean separate track. When the line is documented, the claims pay; when it is not, they deny as cosmetic. Related services: prior authorization service, eligibility verification, medical billing services.