Medical Billing Forum

General Category => New! => Topic started by: Ruthie1972 on August 23, 2016, 09:41:34 AM

Title: Plastic surgery billing
Post by: Ruthie1972 on August 23, 2016, 09:41:34 AM
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
Title: Re: Plastic surgery billing
Post by: Michele on August 23, 2016, 10:02:13 AM
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!
Title: Re: Plastic surgery billing
Post by: PMRNC on August 23, 2016, 06:05:01 PM
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.
Title: Re: Plastic surgery billing
Post by: kristin on August 23, 2016, 09:48:31 PM
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.

Title: Re: Plastic surgery billing
Post by: Ruthie1972 on August 24, 2016, 08:33:32 AM
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.
Title: Re: Plastic surgery billing
Post by: PMRNC on August 24, 2016, 11:57:09 AM
With a specialty such as that and really with any other surgical practice there are always going to be added paper to send, op reports, etc. What I would do is run a report based on CPT code and by carrier so maybe you can take a look to see if it's something that can be addressed. Does he have a contract with Cigna or maybe he has claims being reduced due to U&C? Try to determine if you can find a common denominator with the troublesome carrier. It may just be their policy to request op reports for certain procedures.

Title: Re: Plastic surgery billing
Post by: Michele on August 24, 2016, 12:11:26 PM
Question makes much more sense now.  :)

You may also want to see if there is a provider rep that you could talk to.  Maybe there is something you can do when the claim is submitted to include all that they require to cut down on some of the processing time.