2021 ASC Coding Tips: Best Practices for Combined Cosmetic/Insurance Cases

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.

Documentation

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 medically necessary.

Examples

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.