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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.

 

For additional information on this topic, contact Jennifer Kirschenbaum at (516)-747-6700 ext. 302 or at Jennifer@Kirschenbaumesq.com.

 

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All Rights Reserved. This email is provided for news and information purposes only and does not constitute legal advice or an invitation to an attorney-client relationship. While every effort has been made to ensure the accuracy of the information contained herein, Kirschenbaum & Kirschenbaum PC does not guarantee such accuracy and cannot be held liable for any errors in, any reliance upon this, or losses caused by the information. Under New York’s Code of Professional Responsibility, this material may constitute attorney advertising. Prior results do not guarantee a similar outcome.


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