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Plastic Surgery Billing Services

In plastic surgery, the first billing question is whether insurance should be billed at all. Reconstructive work that restores function or corrects deformity is a medical service with criteria, photos and pre-approval; cosmetic work is a self-pay package with a price agreed in advance. Many patients need both, sometimes in the same operation.

  • Medical necessity documented to the payer's criteria before surgery
  • Breast reconstruction billed under federal reconstruction protections
  • Self-pay quotes kept separate from insured procedures in mixed cases
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Breast reconstruction and the Women's Health and Cancer Rights Act

Under the Women's Health and Cancer Rights Act, group health plans that cover mastectomy must also cover reconstruction of the affected breast, surgery on the other breast so the two match, prostheses, and treatment of physical complications such as lymphedema. That makes most post-mastectomy reconstruction a covered service, even when it involves procedures that would be cosmetic in other contexts.

Coverage still depends on billing it correctly: the cancer history and mastectomy must be documented, the symmetry procedure must be linked to the reconstruction, and staged procedures over many months must stay connected to the original treatment plan.

Proving a procedure is reconstructive

Medicare excludes cosmetic surgery except to promptly repair an accidental injury or to improve the function of a malformed body part, and commercial payers draw their own line between reconstructive and cosmetic work. Most of the billing work happens before surgery: building a request that shows the payer's criteria are met.

Those criteria are procedure-specific and differ between payers. For blepharoplasty, one Medicare contractor relies on photographs rather than visual field testing, while another requires measured visual field loss and treats photographs as optional. One contractor's policy covers panniculectomy when the panniculus hangs below the pubis and causes skin problems that do not respond to treatment, and considers breast reduction for significantly enlarged breasts with listed symptoms. Nasal surgery requests are built on the airway findings and treatment history each payer's policy asks for.

After surgery, the global period still applies. Planned later stages, such as exchanging a tissue expander for an implant, are billed as staged procedures, while complications that need a return to the operating room have their own modifier. Whether a plan covers treatment of a complication after cosmetic surgery is set by the plan, so we check that before the claim is built.

Why reconstructive claims are refused

  • Criteria not documented

    The request lacks the photos, testing, symptom history or conservative treatment the policy lists.

  • Surgery performed before approval

    The approval arrived late or covered a different procedure from the one performed.

  • Cosmetic and medical work on one claim

    A combined procedure billed entirely to insurance instead of separating the covered portion.

  • Staged procedure billed as new surgery

    An expander-to-implant exchange billed without modifier 58 inside the first surgery's global period.

  • Complication care after cosmetic surgery

    Treatment of a cosmetic surgery complication sent to a plan that excludes it.

Reconstruction, functional surgery and implant codes

Codes that drive most insured plastic surgery claims. Confirm against the current code sets and each payer's policy.

Plastic and reconstructive surgery codes with billing notes
CodesProcedureBilling notes
19357Placement of a tissue expander for breast reconstruction, with later expansions included.Expansion visits are included in the code.
19340, 19342Breast implant insertion on the same day as mastectomy, and on a separate day (delayed).Planned later stages inside the global, such as exchanging the expander for a permanent implant, are reported as staged procedures with modifier 58.
19364, S2068Free flap breast reconstruction, and a HCPCS code some payers use for DIEP or similar perforator flaps.Which code a payer wants for perforator flaps varies; confirm before surgery.
19318Breast reduction.Covered only when the payer's medical necessity criteria are met and documented.
15830, 15847Panniculectomy, and abdominoplasty add-on.The abdominoplasty add-on is reported only with 15830, and work done only to improve appearance is generally not covered.
15822, 15823, 30520, 30465Upper eyelid blepharoplasty with and without excess skin weighing down the lid, septoplasty, and nasal valve repair.Functional criteria and testing must be documented for each.
L8600Implantable breast prosthesis.Who bills it depends on the setting and payer, which we confirm with the facility.

CPT is a registered trademark of the American Medical Association.

Official sources: eCFR: 42 CFR 411.15 (cosmetic surgery exclusion) (external site), CMS Medicare Coverage Database: LCD L34194 (blepharoplasty, Noridian) (external site), CMS Medicare Coverage Database: LCD L33944 (blepharoplasty, CGS) (external site), CMS Medicare Coverage Database: LCD L39051 (cosmetic and reconstructive surgery) (external site), CMS: ACA implementation FAQs part 68 (WHCRA) (external site), CMS: HCPCS quarterly file (external site), CMS: coverage database article export (external site), CMS Claims Processing Manual, chapter 12 (external site), eCFR: 45 CFR 149.610 (external site)

Self-pay packages and mixed cases

Cosmetic surgery is usually sold as a package: surgeon fee, facility, anesthesia, implants and routine follow-up, with a deposit and a written refund and revision policy. Uninsured and self-pay patients must also receive a good faith estimate of expected charges for scheduled care under the No Surprises Act.

Mixed cases cause the most disputes. A combined claim sent entirely to insurance is denied or later recouped, and a patient billed late for the cosmetic share disputes the charge. We separate the covered and cosmetic procedures before surgery, agree with the facility and anesthesia group how their charges will be split, and give the patient the self-pay price for the cosmetic part in writing.

Our process from consultation to final claim

  1. Step 1: Classify the case at consultation

    Each planned procedure is marked reconstructive, functional, cosmetic or mixed before any quote or request is made.

  2. Step 2: Assemble the approval packet

    Photos, test results, symptom history and conservative care are gathered against the specific payer policy.

  3. Step 3: Quote the self-pay portion

    Cosmetic components get a written package price and a good faith estimate where required.

  4. Step 4: Track stages and complications

    Planned stages, returns to the OR and global periods are tracked so each later surgery is billed correctly.

  5. Step 5: Coordinate with the facility

    Implants, devices and facility fees are confirmed with the hospital or ASC so nothing is billed twice or missed.

Frequently asked questions

Will insurance cover a breast reduction?

Often, when the payer's criteria are met: documented symptoms such as back, neck or shoulder pain, failed conservative treatment, and the expected amount of tissue removed. Each payer's policy is different, so the request is built to that policy.

Is reconstruction after mastectomy always covered?

Group health plans that cover mastectomy must cover reconstruction, symmetry surgery on the other breast, prostheses and treatment of complications under federal law, subject to the plan's normal cost sharing.

How do we bill a tummy tuck done with a covered panniculectomy?

Bill only the panniculectomy to insurance, if it meets the policy. The abdominoplasty portion is cosmetic and is charged to the patient, including its share of facility and anesthesia time.

What documentation is needed for functional blepharoplasty?

It depends on the Medicare contractor or payer: some policies rely on photographs, others on visual field testing, and all expect the patient's symptoms to be documented.

How are revisions billed?

A planned later stage is billed as a staged procedure. An unplanned return to the operating room for a complication has its own modifier. Revisions for appearance after cosmetic surgery are usually self-pay under the practice's revision policy.

Related services and specialties

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Questions about reconstructive approvals?

Call us to talk through pre-authorizations, mixed cases and self-pay packages, or start with a free billing audit.

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