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JENNIFER KIRSCHENBAUM, ESQ. – HEALTHCARE NEWSLETTER
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Billing Surgery that has Medically Necessary and Cosmetic Component
Q. How/who do I bill for a surgery that has a medically necessary component covered by insurance and a cosmetic component that is not covered by insurance?
When a medically necessary procedure and cosmetic procedure are performed during the same surgery it becomes tricky to define where one ends and the other begins. This becomes relevant in terms of the anesthesia and facility fee. For example I have patients who presents with nasal septal deviation (a medically necessary surgical procedure covered by insurance) and the patient has a cosmetic nasal deformity that they are interested in having fixed surgically (a cosmetic surgical procedure NOT covered by insurance.
Typically for an isolated cosmetic procedure there is a separate surgeon's fee, anesthesia fee and facility fee. However, when a medical and cosmetic procedure are combined, the patient often wonders whether the anesthesia and facility fee for the cosmetic portion can be waived, since the insurance is covering the facility and anesthesia charges for the medical portion and it is often impossible to define when the medical portion ends and the cosmetic portion begins.
A. Dear Dr. ______,
Thank you for your question. This does come up frequently and the practical answer is that you are to bill the insurance company for all medically necessary treatment and all associated charges. To bill the patient separately for anesthesia services and a facility fee on top of what you are recovering from a third party payor is duplicative and may very well be interpreted as insurance fraud.
As there is an element of commingling between the cosmetic and medically necessary procedures, I would recommend making sure you are keeping the best documentation that you can on the medically necessary component. Your note is crucial.
This is the practical answer. The Insurance Department has not issued a direct opinion on this question. The issue here is very clear though, duplicative billing is not allowed, you are to be reimbursed for all medically necessary services and additional costs associated therewith.
The NON-practical answer that some camps of thought may relay is that separate procedures should be performed for each component and that you should perform the medically necessary component on one day and the cosmetic on a separate. This clearly does not take into account the best case scenario for the patient (cost wise or quality of care).
Whichever avenue works best for your practice, always remember that your documentation is key.
******** I welcome and encourage comments on this topic.
Should you have additional questions or concerns please do not hesitate to contact me.
The above information is for education and discussion purposes only. Missed a prior article or looking for previously posted information, check out https://www.kirschenbaumesq.com/healthcarearticles.htm.
Jennifer Kirschenbaum, Esq.
Kirschenbaum & Kirschenbaum, P.C.
200 Garden City Plaza
Garden City, New York 11530
(516) 747-6700 x. 208 (tel)
(516) 747-6781 (fax)
Founded in 1977, KIRSCHENBAUM & KIRSCHENBAUM, P.C., is one of Long Island's most prominent and well-respected mid-size general practice law firms. The firm continues its tradition of providing clients with legal advice and services of the highest quality and maintaining and fostering diversity in its practice. From representing a wide variety of large and small clients in many different industries, our attorneys have the hands-on experience and knowledge needed to handle almost any types of legal matters, whether litigious or transactional in nature.
If You Need Medical Compliance Documents
For additional information on this topic, contact Jennifer Kirschenbaum at (516)-747-6700 ext. 208
or at Jennifer@Kirschenbaumesq.com. Click here to access prior healthcare email newsletters or articles.
Click here to order required policies and procedures for your practice including your:
(i)Compliance Plan (that provides your policies and procedures that identify and govern how to respond to potential billing and general practice liability);
(ii)Current Patient Privacy Policies (HIPAA, Red Flags Rule and Security Policies have recently changed.
Are you up to date?);
(iii)Employee Manual governing employee acceptable conduct; and
(iv)Misconduct Pledge that governs licensure matters.
Questions about why you need the Compliance Program and how the Compliance Program will change your practice? Contact Jennifer at (516) 747-6700 ext. 308 or at Jennifer@Kirschenbaumesq.com.
Our Compliance Program complies with OIG specifications for individual and small group practices. All HIPAA and Security policies include modifications pursuant to HITECH Act. www.kirschenbaumesq.com/healthcareorder.htm.