Wiki COSMETIC EXCISION

LadyT

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My provider wants to do cosmetic excision of keloid but then wants to bill repair to insurance. I do not think this is correct. Any advice would be appreciated!
 
I work for an insurance company and I say you can bill it to insurance because you can bill anything to insurance, but it is all about your intent when you submit your bill. I would suggest you include a diagnosis code that indicates that the procedure was perform for cosmetic reasons in addition to whatever the medical diagnosis is depending on the medical record. You might consider adding ICD-10 codes:
  • Z42.8 - Encounter for other plastic and reconstructive surgery following medical procedure or healed injury
or​
  • Z41.1 - Encounter for cosmetic surgery
You might want to also include modifier GZ with the procedure so that the insurance company knows you believe they would deem the procedure as not medically necessary.

That said, based on the fact that you state a keloid was excised I'm guessing Z42.8 might be most appropriate in this situation. If you include a Z code that indicates that there was a cosmetic component to the reason for the procedure; then you are unlikely to be flagged by the insurance company for trying to bill something that was done for cosmetic purposes and trying to receive reimbursement for a medically necessary reason.
 
I work for an insurance company and I say you can bill it to insurance because you can bill anything to insurance, but it is all about your intent when you submit your bill. I would suggest you include a diagnosis code that indicates that the procedure was perform for cosmetic reasons in addition to whatever the medical diagnosis is depending on the medical record. You might consider adding ICD-10 codes:
  • Z42.8 - Encounter for other plastic and reconstructive surgery following medical procedure or healed injury
or​
  • Z41.1 - Encounter for cosmetic surgery
You might want to also include modifier GZ with the procedure so that the insurance company knows you believe they would deem the procedure as not medically necessary.

That said, based on the fact that you state a keloid was excised I'm guessing Z42.8 might be most appropriate in this situation. If you include a Z code that indicates that there was a cosmetic component to the reason for the procedure; then you are unlikely to be flagged by the insurance company for trying to bill something that was done for cosmetic purposes and trying to receive reimbursement for a medically necessary reason.
Let's attack this from a different angle. Can you bill this to insurance? Sure. Should you bill this to insurance? Per CMS medical necessity is the over-arching factor in choosing a CPT code. In this case, since the incision is based on a cosmetic procedure, there is no medical necessity. No medical necessity, no billable service. In orthopedics we deal with bones breaking during procedures. The surgeon has to repair the fracture, but it is not billable. I do agree with you that if you decide to bill it to use codes that show it was cosmetic. Will insurance make payment on this? Very unlikely.
 
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