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Help Cosmetic Surgeon-Not following CPT

  1. #1
    Columbus Ohio
    Question Help Cosmetic Surgeon-Not following CPT
    Medical Coding Books
    Hello I am hoping someone can help me. I work for a payer and there is a cosmetic surgeon who is billing codes for procedures that were not performed. I sent the provider a letter showing CPT guidelines state that they are billing incorrectly. The provider tells me that they do not follow CPT since they are cosmetic surgeons and they are billing the patient. We have paid them for the procedures that were performed.

    Has anyone ever heard of such a thing? If this is correct, then all cosmetic surgeons could just bill whatever they wanted. If anyone can offer any assistance I would be very greatful as I am sure this patient will.

    I would also like to report this physician to the appropriate people, to make sure he is not billing self pay patients for procedures not performed. As his office told me they don't usually take insurance. Who could we report this physician to if he is not a provider for any insurance companies?

    Thanks again for all your help.

  2. Default Cosmetic Procedures
    Amy, I work for a multispecialty surgery center. We do about 500 cases a month and 25% are "cosmetic" procedures. We always code what procedures were performed by the operative note. If they truly do cosmetic cases that are self pay, they can use what ever codes they want, but if they do a breast reduction 19318 then they must bill that CPT to the payer.

  3. #3
    Milwaukee WI
    Default Who to report to ...
    How about your state's medical society? Or the state's attorney general office or department of commerce (whichever has a consumer protection division). There's also the American Academy of Plastic Surgeons.

    Or maybe you have a local TV station that has an investigative reporter?

    It would be best if the complaint came from the patient, however.

    Billing "whatever we want" just does not make sense. Patients are pretty savvy consumers in this day and age. Why risk any kind of fraud or malpractice claim for a few extra bucks?

    F Tessa Bartels, CPC CEMC

  4. Default
    My understanding is that if the procedures are cosmetic, plastic surgeons can charge whatever they want and the patient will know up front how much the surgery will cost. However, if they then bill insurance, and insurance pays, you must refund the patient and abide by any contracts you may have with the payer.

    If the provider is billing insurance for procedures not done per the documentation, I would report them to the State insurance commission. I would suggest both the insurance company and patient contact them regarding the matter.

    Lisi, CPC

  5. #5
    Columbia, MO
    Correct, they can "charge" what ever they want, not bill whatever they want. They must bill for the procedue they have performed thay cannot use whatever code they want, they can however contract with the patient up front to agree on a charge for the service they will perform.

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