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Plastic Surgery Billing Services
Plastic surgery billing starts with the diagnosis the plan will pay. A reconstructive indication is one claim. A cosmetic request is a different claim. Vector Medical Billing, in Jamaica, New York, keeps that split, the authorization packet, and the global inside the EHR you already use.
98%Published NCR
24hClaim Submission
BAASigned with every client
AAPCCertified coders
AHIMACertified coders
E&OErrors and omissions insured
50 StatesRemote billing nationwide
Monthly fee
What plastic surgery billing services include
Full-cycle RCM for reconstructive and cosmetic practices — the payer claim and the patient-pay line are not the same workflow.
The operating cycle matches medical billing services: eligibility and prior auth, charge capture from consult and operative notes, ICD-10 / CPT coding, scrub, clearinghouse submission, payment posting, denial management, and A/R follow-up. The scrub watches reconstructive versus cosmetic routing, authorization that lists the CPT and the functional reason, photographs and visual-field or symptom criteria when the plan requires them, graft size, breast-reconstruction staging, and 90-day globals.
In scope: office and consult E/M, breast reconstruction after mastectomy, reduction mammaplasty when medical necessity is documented, skin grafts and adjacent-tissue transfer, scar revision and flap work tied to trauma or disease, functional blepharoplasty and rhinoplasty when criteria are met, panniculectomy when it is not a cosmetic abdominoplasty, and cosmetic procedures posted to patient responsibility. Hand surgery that is primarily orthopedic may sit on orthopedic billing. Mohs and office dermatology sit on dermatology billing. Facility fees stay on the ASC or hospital claim.
Plastic surgery is priced as a percentage of net collections with other high-scrub surgical work. The written rate follows how much of the book is insured reconstruction versus self-pay cosmetic on pricing. Credentialing, a retrospective coding audit, MIPS, and out-of-network / IDR stay separate engagements.
What sits on this plastic surgery fee
- Reconstructive claims and cosmetic patient-pay kept apart
- Auth packets, graft size, and globals scrubbed before submission
- HIPAA workflows, a signed BAA, and PHI limited to staff on the account
Where plastic surgery claims fail
Patterns LCD cosmetic exclusions and specialty plastic RCM keep naming.
Cosmetic sent as reconstruction
Appearance-only rhinoplasty, abdominoplasty, or eyelid surgery submitted with a functional diagnosis the note does not support. Photos and symptom criteria missing from the auth packet.
Hub rule: a reconstructive diagnosis is what the plan pays. A cosmetic request is a different claim.
Graft and stage mismatches
Split-thickness graft units that do not match square centimeters. Adjacent-tissue transfer billed as a simple closure. Expander fills billed again after 19357, which already includes subsequent expansions.
Size, site, and stage come from the operative note.
Global and mixed-day leaks
Routine post-op inside a 90-day reconstruction billed as a new visit. A same-day cosmetic add-on left on the insurance claim, or a covered functional portion left off because the rest of the day was cosmetic.
Split the day when both kinds of work are real.
Reconstructive · cosmetic
A reconstructive diagnosis versus a cosmetic request
Hub language made operational: function and deformity on one claim, appearance-only on another.
Reconstructive surgery repairs abnormal structure from congenital anomaly, trauma, infection, tumor, or disease, or restores function. Plans may cover it when the note, photographs, and prior authorization show that purpose. Cosmetic surgery reshapes normal structures to change appearance. Medicare excludes cosmetic surgery except when it is prompt repair of accidental injury or to improve function of a malformed body member. A therapeutic operation that also changes appearance can still be covered. Emotional distress alone is not a reconstructive diagnosis.
Cosmetic work is usually patient responsibility under a written estimate before the day. If a secondary plan needs a Medicare denial, modifier GY can be used to request a statutory-exclusion denial — it is not a way to get the line paid. Complications during the stay for a non-covered cosmetic procedure are often non-covered as related services. An unrelated problem can still be a covered claim when the record separates it.
Before the case is booked
- Diagnosis and photos match reconstructive criteria, or the estimate is patient-pay
- Auth lists the CPT codes that will be performed
- Same-day cosmetic add-ons stay off the insurance claim
Eyelids, nose, and abdominal contour
The same CPT family can be covered or cosmetic depending on the indication in the chart.
Blepharoplasty and rhinoplasty
Upper-lid blepharoplasty (often 15823) is considered when excess skin blocks the visual field and testing or photographs meet the plan’s threshold. Appearance-only lids are cosmetic. Functional rhinoplasty or septorhinoplasty needs obstruction, trauma, or congenital findings — not a cosmetic tip change. We do not attach a functional diagnosis to a cosmetic operative note.
Panniculectomy versus abdominoplasty
Panniculectomy (15830) may be reconstructive when a hanging pannus causes documented rashes, infections, or functional limits and conservative care has failed — usually with photos and auth. Abdominoplasty and muscle plication aimed at contour are cosmetic on most policies, including many add-on codes. Diastasis repair alone is commonly excluded. Do not substitute one code for the other to chase coverage.
Breast reconstruction, reduction, and grafts
Stage the reconstruction. Size the graft. Do not rebill work the code already includes.
Reconstruction after mastectomy
Reconstruction of the breast on which a mastectomy was performed, and surgery on the opposite breast to produce symmetry when the plan covers it, is a reconstructive path — not a cosmetic augmentation. Tissue-expander placement (19357) includes subsequent expansions. Implant, flap, and later revision codes follow the stage in the note and the global already open. Group health plans that cover mastectomy generally must cover reconstruction under federal rules; we still match the specific plan’s auth list.
Reduction mammaplasty
Reduction (19318) needs the plan’s medical-necessity packet: symptoms, conservative care, and often estimated tissue weight. Cosmetic reduction without those findings is patient-pay. Bilateral reporting follows 50 or RT/LT rules for that payer. Do not use an implant-augmentation code for a reduction.
Grafts and adjacent tissue
Split- and full-thickness grafts (15100 and 15200 families) are chosen by site and by square centimeters, with add-ons for additional area. Adjacent-tissue transfer (14000 family) is not a simple repair. Defect size in the note has to support the units. A graft included in another reconstruction descriptor is not billed again.
Globals and the mixed operative day
Covered work and cosmetic work can share a date without sharing a claim.
90-day reconstructive package
Major reconstructive procedures usually carry a 90-day global. Routine related visits stay in the package. Modifier 57 is the first decision for major surgery. Modifier 24 is an unrelated problem. Staged reconstruction uses 58 when the plan was staged. An unplanned return to the operating room for a related complication uses 78. Do not bill expander fills that 19357 already includes as post-op procedures.
One day, two responsibilities
When a covered functional procedure and a cosmetic add-on happen the same day, the insurance claim carries only the covered CPT and diagnosis. The cosmetic portion is estimated and collected as patient responsibility. Modifier 59 or XS is used only when two covered services are truly separate — not to force a cosmetic line through an edit.
Plastic surgery code families this service works
Illustrative anchors — the indication, photos, and auth decide whether the line is a plan claim.
| Work type | Example | What to check | Common failure if skipped |
|---|---|---|---|
| Reconstructive vs cosmetic | Diagnosis + photos | Function or deformity | Appearance billed to the plan |
| Statutory exclusion denial | GY when needed | Secondary needs a denial | GY used to seek payment |
| Blepharoplasty | 15822 / 15823 | Visual field / photos | Cosmetic lids on insurance |
| Rhinoplasty | 30400–30420 / functional | Obstruction or trauma | Tip change as functional |
| Panniculectomy | 15830 | Not abdominoplasty | Contour code swapped in |
| Tissue expander | 19357 | Includes later expansions | Fills rebilled |
| Reduction | 19318 | Symptom packet / weight | No conservative-care note |
| Split graft | 15100 / +15101 | Site and cm² | Units over the defect |
| Adjacent tissue | 14000 family | Not simple repair | Closure unbundled |
| Global visit | 24 / 57 / 58 / 78 | Related vs unrelated | Routine post-op billed |
This page does not invent a plastic surgery denial percentage. The free audit reads your cosmetic-versus-reconstructive routing, graft units, and global visits on the sample you send.
What a free audit line looks like
Illustrative composite only — not a client result and not a promised recovery.
| Field | Example entry |
|---|---|
| Documented service | Post-mastectomy tissue expander on the right; cosmetic liposuction of the flanks the same day; expansion visit three weeks later |
| Billed codes | 19357 and flank liposuction on one insurance claim; second procedure code for the expansion visit |
| Issue found | Cosmetic liposuction mixed onto the reconstructive claim; expansion already included in 19357 |
| Recommended correction | Bill 19357 to the plan with the mastectomy-reconstruction diagnosis and auth; collect liposuction as patient-pay; do not bill the routine expansion as a new procedure |
| Related check | Opposite-breast symmetry only if that plan covers it and it was authorized |
| Why it matters | A cosmetic line can take the reconstructive claim down with it — caught in scrub or flagged in the free audit |
Request a Free Audit with recent operative notes, auth letters, claims, and denials. We map reconstructive versus cosmetic lines on your file — not this composite.
How Vector runs plastic surgery billing
Indication and auth first — then the same revenue cycle.
1
Assign plastics
Coder and biller who already separate reconstructive criteria from cosmetic patient-pay.
2
Reconcile and code
Charge entry and coding from the note and photos — queries when function is not documented.
3
Scrub and submit
Claims submission after auth, size, and global checks. Cosmetic lines stay off the plan claim.
4
Post and report
835 posting, denial work, A/R aging, monthly RCM report by reconstruction versus patient-pay.
Not inside the plastic surgery percentage
Related work stays separate so the quote matches the job.
ASC / hospital facility fees
Technical facility and implant charges stay on the ASC or hospital NPI. We bill the professional service your surgeons perform.
Credentialing / audit
Credentialing and a retrospective coding audit of reconstructive versus cosmetic routing are separate engagements when scoped.
Underpay / OON
Underpayment recovery and OON / IDR stay separate when the dispute path is not ordinary denial work.
How plastic surgery billing is priced
Percentage of dollars that land — not a flat fee per case that ignores cosmetic write-off.
Written rate
Plastic surgery is priced as a percentage of net collections because authorization, cosmetic separation, and globals take more scrub and follow-up time. No setup fee on the monthly cycle. Month to month. The written rate follows reconstructive versus cosmetic mix and how much of the cycle you hand over.
See pricing or request a written rate after the free audit.
What we need to start
EHR access, monthly reconstructive versus cosmetic census, top procedures, open A/R if you are leaving another biller, and a sample of medical-necessity denials. Switching usually overlaps so claim submission does not stop. See EHR integration if access setup needs a separate quote.
Audit the claims that send cosmetic work to the plan
Send monthly case mix, top reconstructive procedures, EHR name, and a sample of medical-necessity denials. We reply with what the open A/R shows, whether the monthly fee fits, and a written rate — without inventing a clean-claim percentage.
Written
Monthly rate
98%
Published NCR
50
US States
BAA
Every Client
Plastic surgery billing questions
Straight answers tied to the sections above.
What does plastic surgery billing include?
Reconstructive professional claims, cosmetic patient-pay, breast reconstruction, grafts, functional eyelid and nasal surgery when criteria are met, global tracking, scrubbing, submission, posting, denials, and A/R.
How much do plastic surgery billing services cost?
The fee is a percentage of net collections. No setup fee on the monthly cycle. The written rate follows reconstructive versus cosmetic mix.
Is cosmetic surgery billed to the plan?
No. Cosmetic reshaping of normal structures is patient responsibility. A reconstructive diagnosis that restores function or corrects deformity from trauma, disease, or congenital anomaly is the claim the plan may pay after authorization.
Are expander fills billed after 19357?
No. Tissue-expander placement in breast reconstruction includes subsequent expansions. Routine fill visits are not a second procedure.
When is blepharoplasty covered?
When excess lid skin causes documented visual-field obstruction and the plan’s photo or testing criteria are met. Appearance-only eyelid surgery is cosmetic.
Do we have to change our EHR?
No. Billers work in the system you already use — see EHR integration. Compatibility is confirmed before you commit.
Where does Vector provide plastic surgery billing?
The office is 15717 85th St, Jamaica, NY 11414-2620. Work is remote for plastic surgery practices in all 50 states. See the specialties hub.
Is Vector Medical Billing HIPAA certified?
HHS does not certify billing companies. Vector signs a BAA, limits PHI to staff on the account, and follows HIPAA workflows. A HIPAA security risk analysis is a separate engagement when scoped.