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Summer 2008


Compliance Corner: How To Report Anesthesia for Cosmetic Surgeries

Steve Berman
Vice President of Compliance, ABC

As part of our desire to keep both clients and readers up to date, the Communiqué has been printing compliance information since its inception. In the Compliance Corner, we will now formally keep you abreast of the various compliance issues and/or pick out a topic that would be of interest to most of our readers.

One of the many items that our coders and others deal with on a regular basis is how to address surgeries that have a cosmetic component. When the entire case is cosmetic there is very little difficulty in knowing how to bill. Most insurance carriers will not pay for cosmetic procedures without prior authorization. In such cases, the patient will be billed directly for the procedure unless he or she has pre-paid.

Some cases appear to be cosmetic based on the procedure that was done, and yet the anesthesiologist (or the patient!) requests that the insurance company be billed. If the insurance company is one that pays for cosmetic procedures then it is expected that there should be a pre-authorization number in the file. If the demographic sheet says that the procedure is cosmetic, it should be billed as such.

When the case includes both a covered service and a cosmetic service it is important to provide all the information needed to bill. Ideally, the anesthesia record and/or charge ticket should show the distinct start and stop times of the covered service and of the cosmetic service respectively. The total anesthesia time billed must be split accordingly between the patient and the insurance company. In some cases the covered and cosmetic surgery does not have clearly delineated times. If that occurs, the documentation should reflect the total time for the case, including indication on the anesthesia record of how much time the cosmetic procedure took. Then the base and time of the covered service would be billed to the insurance company and any additional base plus time units would be billed directly to the patient.

It is important that the anesthesia provider not try to bill a cosmetic procedure as a covered service when s/he knows that the service is cosmetic. This is important not just because of potential fraud issues, but also because when the insurance company gets the cosmetic bill, it will deny the entire claim and delay the billing of the patient. If the insurer does pay on the basis of misleading coding, and if the practice is audited after the payment, there could be restitution and penalties. The best way to handle cosmetic surgery cases is to obtain payment from the patient in advance, which is the procedure used by many anesthesia groups.