By Mandeara Frye, RHIA, CPC, CPMA, CASCC, Director of Coding
It’s not uncommon for a surgeon to perform a cosmetic procedure during
the same surgical encounter as a medically necessary procedure. It tends
to be safer for the patient (avoiding undergoing general anesthesia multiple
times), more convenient, and more cost-effective for the surgeon and facility.
To simplify the coding and billing process for these combined cases, here
are some best practices to follow.
Ideally, you should document a separate operative report for each portion
of the case, with cosmetic procedures dictated separately from the medically
necessary procedures. This clearly distinguishes each aspect of the case,
allowing the coder to easily identify the separate procedures and apply
the appropriate CPT codes.
The separation also helps when the insurance company requests medical records
for the medically necessary procedures. If they are documented in their
own report, then the payer will also have clear records to support the
claim they are reviewing.
Some providers may prefer to dictate a single operative report for the
entire surgical case. In this instance, it is critical that the surgeon
specify in the report which of the procedures are cosmetic and which are
Septorhinoplasty — Patients undergoing corrective surgery for a deviated septum (septoplasty)
may also want a cosmetic correction of their nose (rhinoplasty). Since
these procedures are being performed on the same body structure, it makes
sense to have both procedures performed at the same time. The documentation
will guide the coding for this procedure, so if the insurance is to be
billed for the septoplasty, it must be clear that the rhinoplasty is cosmetic.
Combined report, without clarification of cosmetic vs. medically necessary = 30420
(Rhinoplasty, primary; including major septal repair)
Report separating procedures as cosmetic vs. medically necessary = 30520 (Septoplasty or submucous resection, with or without cartilage scoring,
contouring or replacement with graft and 30400
Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip)
Blepharoptosis Repair and Cosmetic Blepharoplasty — The
NCCI manual states medically necessary blepharoplasty is included in blepharoptosis
repair. However, a cosmetic blepharoplasty can be separately reported
and billed to the patient. If the documentation does not specify that
the blepharoplasty is cosmetic, it will be omitted when the case is coded.
In addition to proper documentation, it’s important to have patients
sign an advance beneficiary notice (ABN) acknowledging their understanding
that they will be responsible for the cosmetic expense.
Abdominoplasty and Hernia Repair — It’s common to repair an umbilical hernia while performing
an abdominoplasty for cosmetic purposes. The abdominoplasty bundles into
the hernia repair, so it should be clear in the documentation that the
hernia is medically necessary and the abdominoplasty is cosmetic. This
way, both will be captured for appropriate billing to the insurance company
and patient, respectively.