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Plastic surgery billing

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Ruthie1972:
Hi Everyone
I have an interview with a plastic surgeon to do billing. Any tips on how to get paid for breast reconstruction, I know this billing is mostly for cosmetic. Any tips? Hints on clean claims and getting paid? Any feedback is appreciated. Have a great day. ;D

Michele:
Did they specifically mention that they are having trouble with breast reconstruction claims?  Just seems like a strange question.  The problem with the question is that you should not be looking at it as "how to get paid".  The issue is really "is the service covered".  If the reconstruction is due to a medical issue (post mastectomy due to malignant neoplasm) then most plans cover it.  It would be coded as a reconstruction with the diagnosis of the breast cancer.  If it is cosmetic it should be coded as such.  Be careful not to get into the game of "what do I need to do to get the claim paid".  Sometimes as billers we want to make sure everything is paid.  Which of course is part of our job.  But we want to make sure that everything that should be paid is paid. 

I hope I'm not being a downer, just want to make sure we as billers remember that we can't change things to simply get them paid, we have to make sure the claim is submitted for the services received.

Good luck with the interview!

PMRNC:
Michele pretty much said what I would say.

Reimbursement for these services is determined based on the provider's documentation. Carriers will pay for reconstruction with proper dx such as Breast cancer.

It's important with this specialty to make sure if YOU are NOT  certified coder you make that known to the potential client so that you are not drawn into services that could harm your business.

kristin:
I echo Michele and Linda's responses...if the patient's insurance covers breast reconstruction, and the patient is having it done for a covered diagnosis, then you have a clean claim.

Granted, this doesn't mean insurance will always process as a clean claim, but knowing what the medical policy/LCD is for each insurance being billed is half the battle, or more.

Curious to know where this question came from...the potential client, or you, trying to foresee what the client might ask?

If the client is the one asking, and asking in such a way as to indicate they are just "looking to get paid by insurance, what do I need to do to make that happen?", then be very wary.

Ruthie1972:
Hello All,
Thank you for your responses. I guess I "worded" my question incorrectly. The question was what you answered. The physician does his own coding and is very thorough. I am just not versed with cosmetic surgery. The breast reconstructions he does are due to patient that have had breast cancer and he stated that he has a lot of trouble with Cigna. He  also said his office has to send a lot of paper claims due to the fact that they have to show the operative notes in order to get paid. Just wanted to see if there was any feedback as to what some insurance companies require with the reconstruction. I am sure if  I do get the job it will be like the other I have had and just learn what each one wants as I go along. Have a great day and thank you again.

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