Proving Medical Necessity is Key to Facial Plastic Surgery Reimbursement
Published on Wed Sep 01, 1999
Patients who have facial injuries from an accident or who have cancer of the head, neck or face, often require reconstruction procedures. But these procedures are frequently rejected as cosmetic by payers, even though the repair may be a standard procedure that allows skin to heal or fills empty space after the removal of a tumor.
For otolaryngologists who perform reconstructive plastic surgery, this means the medical necessity of the procedures performed needs to be clearly reported. For example, facial wounds and surgical defects that are deep or under tension may require layered repair to get adequate support while healing.
Examples of such procedures include rhinoplasty, mandibular reconstruction, and reconstruction after Mohs surgery, says Gretchen Segado, CPC, an ENT practice coder who works as assistant compliance officer at Thomas Jefferson University in Philadelphia, PA. Often these procedures, among others, are performed for functional rather than cosmetic reasons, she says.
But the coding software used by carriers may automatically edit out plastic surgery procedures without taking into account both the specific nature of the work done in any particular case and the potential future cost to the carrier if the procedure is not performed.
Diagnosis Codes Key to Rhinoplasty
Take rhinoplasty (30400-30462), for example. Although this procedure is often done for cosmetic reasons, it is also performed when there is internal collapse of the nose. The patient may have cancer, or may have been bitten by an animal.
Sometimes, a rhinoplasty may be performed when the physician reshapes a patients deviated septum (30520, septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) because the patients functional airway is obstructed. In such cases, the septum is usually deformed and the bony pyramid is out of place, so the rhinoplasty is needed to modify the external bony and cartilage structures on the nose and septum. In other words, because the internal and external parts of the nose are related, sometimes it is medically necessary to perform both procedures.
To be properly reimbursed, you must include diagnosis codes that indicate the medical necessity of the procedures. For the example above, the correct diagnosis codes would be 478.1 (other diseases of nasal cavity and sinuses; abscess, necrosis or ulcer of nose [septum]; cyst or mucocele of sinus [nasal]; rhinolith); 738.0 (acquired deformity of nose; deformity of nose [acquired]; overdevelopment of nasal bones); 905.0 (late effect of fracture of skull and face bones); and 784.9 (other symptoms involving head and neck).
She adds that in these cases the pre-certification process is critical. And thorough documentation must be provided by the otolaryngologist to further drive home the medical necessity of the procedure. The documentation can include photographs, which can have [...]
