Plastic and reconstructive surgery is a specialized medical field that focuses on repairing, reconstructing, or altering the human body to improve function or appearance. These practices typically perform multiple procedures daily, from facelifts and breast augmentations to medically necessary reconstructions like post-mastectomy breast reconstruction and congenital disability repair.

Medical billing can become quite complex given the volume and variety of procedures, especially in a populated area like New York. The frequent occurrence of multiple procedures and co-surgeries makes it challenging for billers to manage coding requirements, prior authorizations, insurance limitations, and compliance issues. However, partnering with a specialized medical billing provider like StarkBilling can make all the difference in overcoming these hurdles.

Here, we discuss the specific billing challenges that plastic and reconstructive surgeons face and how a New York medical billing provider can help.

The Biggest Challenges of Plastic and Reconstructive Surgery Billing

Plastic and reconstructive surgery in New York encompasses various procedures, from cosmetic enhancements to medically necessary reconstructions. However, like any medical specialty, it faces specific roadblocks regarding medical billing.

Each procedure has its own billing challenges that can complicate reimbursement. These include varying wound repair codes and the necessity of using the correct surgical and E/M modifier codes. Additionally, since plastic and reconstructive surgery can be costly, adhering to guidelines is crucial.

Let’s explore the key difficulties faced by plastic and reconstructive surgeons in New York.

Compliance with Regulations

In-house billers and coders for plastic and reconstructive surgery practices have their hands full. They must stay up to date with annual changes to surgery codes while also being aware of insurance requirements of medical necessity when submitting claims. As a result, these tasks can be confusing, which can lead to errors like billing for procedures not covered by insurance, incorrect coding, billing for more expensive procedures without realizing it, or billing for multiple codes for one procedure instead of one bundle, leading to serious compliance problems.

Ensuring compliance requires constant vigilance and knowledge to avoid these pitfalls and maintain proper billing practices.

Insurance Limitations

Insurance coverage for plastic surgery and reconstruction can take time to acquire, depending on the reason for the procedure. Surgery or procedures are often covered by insurance when they are deemed medically necessary, which means the service is needed to diagnose or treat an illness, injury, or condition.

This is typically not the case when it comes to cosmetic procedures. For example, a facelift performed purely for cosmetic reasons, such as to address aging concerns, would not be covered by insurance. Conversely, a blepharoplasty (eyelid lift) performed to correct excess eyelid skin affecting vision would be partially covered, as it is considered medically necessary. Other examples include rhinoplasty for severe breathing or sleeping issues and breast augmentation or reconstruction following a mastectomy for breast cancer.

Challenging Coding Requirements

Plastic and reconstructive surgery involve complex procedures with multiple components, such as anesthesia, surgical techniques, and post-operative care. This degree of difficulty makes coding particularly challenging. Additionally, the lack of standardization further complicates the process, as codes in plastic surgery and reconstruction are constantly evolving. Accurate documentation and navigating insurance coverage requirements add layers of difficulty, making it essential for billers to stay updated to ensure accurate reimbursement.

Prior Authorization

Prior authorization is a major challenge for patients and providers in plastic surgery and reconstruction. Insurance providers often impose roadblocks due to concerns about medical necessity and cost. They may refuse to cover plastic surgery or reconstruction, suggesting nonoperative therapies instead, even when surgery is more appropriate. This makes the process difficult for in-house billers, particularly those inexperienced with this type of billing.

Challenges like these are common in plastic and reconstructive surgical practices. While there are many ways to overcome them, they can be time-consuming and affect how providers and staff interact with patients and complete other essential tasks. Fortunately, partnering with a specialized medical billing provider like StarkBilling offers an effective solution.

Overcoming Medical Billing Challenges with StarkBilling

Plastic and reconstructive surgery providers face several challenges, from insurance limitations to constantly changing ICD updates. While these factors can make billing and coding for these procedures daunting and frustrating, there are ways to improve revenue cycle management, submit claims accurately, and accelerate cash flow.

Partnering with a specialized medical billing provider like StarkBilling, which has forty years of experience in the healthcare industry, can help plastic and reconstructive providers in New York enhance their billing processes and achieve greater success. Here are the key benefits of working with a dedicated medical billing partner.

Experts in Plastic and Reconstructive Surgery Coding

StarkBilling brings decades of experience in specialized medical billing, and its team members are experts in plastic and reconstructive surgery coding. They stay up to date with evolving codes and can accurately manage the demanding documentation requirements. Their expertise enables them to manage challenging insurance demands efficiently, ensuring accurate and compliant billing practices for their clients.

Guidance in Prior Authorization Process

StarkBilling plays an advisory role in the prior authorization process. While providers are responsible for obtaining the actual authorizations, StarkBilling alerts them to any pre-authorization issues that result in denials. With this additional help, providers can address problems more quickly, minimizing delays and improving approval rates.

Managing Insurance Limitations

Managing insurance limitations is one of the most challenging aspects of plastic and reconstructive surgery medical billing. StarkBilling’s experienced professionals are well-versed in the procedures deemed necessary and understand the codes. Their expertise can reduce denials and improve collections by ensuring accurate and compliant billing. They also help clients cope more effectively with insurance limitations, leading to better financial outcomes.

Ensuring Regulatory Compliance

Plastic surgery practices must adhere to coding and billing guidelines set by the Centers for Medicare and Medicaid Services and private insurance payers. Unfortunately, when practice falls out of compliance, it can lead to significant issues, such as financial penalties, legal issues, and reputational damage. Common compliance risks in plastic surgery billing include upcoding, unbundling, double billing, and false claims.

StarkBilling helps providers stay current with these regulations and guidelines, ensuring that they avoid missteps, maintain compliance, and safeguard financial stability and reputation.

Conclusion

Plastic and reconstructive surgery practices in New York face numerous medical billing challenges, including constantly changing coding requirements, prior authorization issues, demanding insurance limitations, and compliance risks. While training and ongoing education can help address these difficulties, partnering with a specialized medical billing provider like StarkBilling offers a more comprehensive solution. Its expertise in plastic and reconstructive surgical coding helps surgical groups manage challenging insurance demands, ensure accurate and compliant billing practices, and improve revenue.

Capture more revenue, and expand your New York surgical practice by partnering with a specialized medical billing team that has in-depth knowledge of the coding requirements for your diverse procedures. Schedule a free consultation now.