Plastic & Reconstructive Surgery Billing Audit
Protect covered reconstructive cases with the documentation, authorizations and coding payers look for — and keep cosmetic work cleanly separated.
Reconstructive plastic surgery is paid only when the payer agrees the procedure corrects a functional problem, so most denials trace back to documentation gathered before the case. Payers typically want measurements, photographs and history — for example visual-field testing for blepharoplasty, or symptoms and failed conservative treatment for breast reduction — and many require prior authorization. Coding then has to follow size- and site-based rules for adjacent tissue transfers, grafts and repairs. Our audit reviews the pre-operative evidence, authorizations and operative notes together, checks how cosmetic and reconstructive parts of combined cases were split, and confirms breast reconstruction after mastectomy is billed with the coverage protections federal law provides.
Audit red flags
- Reconstructive cases scheduled before prior authorization was approved, or billed under an authorization for a different CPT code.
- Blepharoplasty and breast-reduction claims without the measurements, photographs or testing the payer policy requires.
- Combined cosmetic and reconstructive cases where the covered portion is not clearly documented and billed separately.
- Lesion excisions billed separately on the same site as an adjacent tissue transfer.
Audit action plan
- 1. Pre-Operative Evidence Review — Check that the photographs, measurements, testing and conservative-treatment history each payer requires were on file before surgery.
- 2. Authorization Reconciliation — Match authorizations to the CPT codes and dates actually billed to find cases performed outside what was approved.
- 3. Operative Coding Review — Confirm flap, graft and repair codes match the documented sizes and sites, and that bundled services were not billed separately.
Codes reviewed
- 15822 / 15823 — Upper eyelid blepharoplasty / with excessive skin weighting down the lid
- 19318 — Breast reduction
- 19357 / 19340 — Breast reconstruction with tissue expander / implant on the same day as mastectomy
- 14000–14350 — Adjacent tissue transfer or rearrangement
Frequently asked questions
How do payers decide if a procedure is reconstructive or cosmetic?
Most payers publish medical policies listing the functional problems and documentation they accept, such as visual-field loss for eyelid surgery or pain and failed conservative treatment for breast reduction. If the documentation does not meet the policy, the procedure is treated as cosmetic and denied.
Is breast reconstruction after mastectomy always covered?
Under the federal Women's Health and Cancer Rights Act, group health plans and insurers that cover mastectomy must also cover reconstruction, including surgery on the other breast for symmetry. Prior authorization and documentation requirements still apply.
Can a surgeon bill for a cosmetic and a covered procedure in the same session?
Yes, but the covered procedure must be documented and billed on its own merits, and the patient pays for the cosmetic portion. Clear operative notes and a separate financial agreement for the cosmetic work protect both the claim and the practice.