Eyeworld

by Paul M. Larson, M.B.A., M.M.Sc., C.O.M.T., C.O.E., C.P.C.; Peter J. Sakol, M.D., J.D.; and Kevin J. Corcoran, C.O.E., C.P.C., F.N.A.O. Cosmetic or reconstructive surgery: How to decide? P atients often ask the doc- tor at the initial consulta- tion whether their surgery will be considered cos- metic or not. This distinc- tion is critically important and determines who pays for the proce- dure—the patient or the insurance carrier. Unfortunately, the primary reference for coding, current proce- dural terminology (CPT), does not specify if a particular code is always reconstructive or always cosmetic. To add to the confusion, some insur- ance carriers disagree on this point. An understanding of this topic helps determine who pays for the surgery so when surgery is scheduled there is good communication with the pa- tient and few surprises thereafter. By definition, cosmetic surgery is performed to improve appearance while reconstructive surgery is performed to restore or improve function, although incidental im- provement in appearance may also occur. 1 Reconstructive surgery is usu- ally performed on abnormal struc- tures of the body and caused by congenital defects, developmental abnormalities, trauma, infection, tu- mors, or disease. In general, recon- structive surgery is covered by insur- ance, but cosmetic surgery is not. Within the Medicare program, cos- metic surgery is statutorily excluded from coverage by the Social Security Act 2 so that Medicare beneficiaries are financially responsible for it. Most Medicare carriers publish policies (i.e., local coverage determi- nation) that outline the eligibility guidelines for the most common procedures. Other third-party payers may publish their own, possibly dif- ferent, rules to differentiate between covered and non-covered proce- dures. Administrators, physicians, and staff must understand the vari- ous coverage rules before the surgery takes place in order to ensure proper reimbursement and avoid confusion. By default, third-party payers tend to categorize the most common oculoplastics procedures, eyelid and brow surgery, as cosmetic. If reim- bursement is expected or desired, it is essential that the chart documen- tation, as well as the request for prior authorization, contain the nec- essary information to support cover- age. Check each payer's coverage policy beforehand. Obtain a verifica- tion of "no policy" or get a pre-au- thorization for the planned surgery, but understand that pre-authoriza- tion is no guarantee of payment. The distinction between cos- metic surgery and reconstructive or functional surgery is based on the following: • Patient's complaint(s) and history • Findings of the examination and key measurements • Results of diagnostic tests • Purpose and extent of the surgery Surgeons and patients each have vested interests in the determina- tion. The two perspectives almost as- suredly are diametrically opposed, with patients sometimes pressing the surgeon to show that the surgery is wholly reconstructive and sur- geons preferring to categorize bor- derline cases as wholly cosmetic to avoid the lower fees engendered by assignment provisions. Additionally, some procedures may be a combina- tion of cosmetic and reconstructive procedures. Ethics and clinical judg- ment play a significant role in sepa- rating the two. Once a fair determination has been made, a discussion of financial responsibility can take place. Obvi- ous situations are easily handled, but borderline cases require a con- tingency plan for financial reversals. The best tool is a financial waiver. For Medicare, this is the Advance Beneficiary Notice of Noncoverage (ABN); for other payers, this is the Notice of Exclusion of Health Plan Benefits (NEHB). In cases where re- imbursement is doubtful, pre-pay- ment is recommended. If a payer de- termines later that the procedure is medically necessary, covered, and subject to the fee schedule, then a prompt refund is due to the patient. In the first paragraph of the op- erative report, a short description of the indications for the surgery is very helpful. If, at a later date, the beneficiary or payer question the coverage and payment decision, a request for the operative report and associated chart notes is certain. Be- cause some cases have both cosmetic and reconstructive portions, it is im- portant that the surgeon state which is which. Two separate operative notes are not recommended or needed. Carefully delineating the vari- ous financial responsibilities beforehand as well as being sure to properly document by examination and operative note are key to avoid- ing problems. Of course, surprises are possible where reimbursement is concerned, but following the basics noted here may help minimize them. EW References 1. American Society of Plastic Surgery 2. Social Security Act, 1862(a)(1) EW Ophthalmology Business 58 June 2011 Reconstructive Cosmetic Vision impairment, disability Wrinkles, bags, puffiness, loose skin Significant visual field defect Normal visual field (or nearly) Restore function or relieve pain Better cosmesis Extensive surgery Minimal to moderate surgery Slow recovery following surgery Rapid recovery following surgery Photos show severe abnormality Photos show mild abnormality Covered by insurance Patient pay ABOUT THE AUTHOR Mr. Corcoran is president and co-owner of Corcoran Consulting Group, San Bernardino, Calif. Mr. Larson is an associate consultant with Corcoran Consulting Group. Dr. Sakol is a consultant with Corcoran Consulting Group. They can be contacted at 800-399-6565.

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