What distinguishes cosmetic from reconstructive plastic surgery for billing?

Reconstructive surgery restores function or normal appearance after injury, disease, or congenital defect and is typically covered by insurance. Cosmetic surgery improves appearance beyond 'normal' range and is patient-pay. Document: underlying diagnosis (not just cosmetic complaint), functional impairment if present, and how procedure addresses medical necessity for insurance coverage of reconstructive procedures.

What documentation is required for cosmetic surgery consultations?

Document: patient's specific concerns and goals, realistic expectations assessment, physical examination with measurements, photographic documentation with consent, procedure options discussed with risks/benefits, alternative treatments considered, informed consent process, and financial discussion. Cosmetic procedures require clear documentation of patient goals and understanding.

How should reconstructive surgery medical necessity be documented?

Document: underlying diagnosis (trauma, cancer resection, congenital defect, functional impairment), specific functional limitation (visual field obstruction for blepharoplasty, pain or functional limitation for breast reduction), conservative treatment if applicable, and how procedure addresses functional deficit. Include measurements (ptosis degree, breast weight) when relevant to coverage criteria.

What preoperative documentation is required for plastic surgery?

Document: medical clearance status (cardiac, anesthesia), smoking cessation (critical for wound healing - document dates), BMI and weight stability, medication review (stop anticoagulants, supplements), photographic documentation with signed consent, detailed surgical plan, risks specific to procedure, and realistic outcome expectations. Inadequate preoperative documentation increases surgical risk.

What CPT codes are commonly used for plastic surgery procedures?

Breast: 19316-19396 (reconstruction), 19318 (reduction). Face: 15780-15783 (dermabrasion), 15820-15823 (blepharoplasty), 15824-15829 (rhytidectomy). Body: 15830-15839 (abdominoplasty), 15876-15879 (suction lipectomy). Reconstructive codes require documented medical necessity; cosmetic codes typically use same CPT but may not be covered by insurance.

Plastic Surgery Consultation Template - Cosmetic & Reconstructive

Visit Information

Date: [Date]
Visit type: Cosmetic Consult / Reconstructive Consult / Follow-up / Post-op
Referring provider: [Name] (if applicable)

Chief Complaint / Goals

Patient's primary concern: [Area of concern]
Desired outcome: [Specific aesthetic or functional goals]
Duration of concern: [Duration]

History of Present Illness

Concerns: [Detailed description of cosmetic or functional issue]
Previous treatments: [Prior surgeries, injections, lasers]
Impact on quality of life: [Pain, function, self-esteem, social interaction]
Weight stability: [Stable, fluctuating, recent loss/gain]

Medical History

Prior Surgeries: [List with dates and complications, specifically scarring/keloids]
Medical Conditions: [HTN, DM, bleeding disorders, autoimmune]
Smoking Status: Current / Former / Never (Critical for healing)
Medications: [Blood thinners, supplements, herbal meds]
Allergies: [Latex, tape, adhesives, antibiotics]

Physical Examination

General: Well-developed, well-nourished. Skin: [Texture, laxity, quality, scars, striae] Head and Neck (if applicable):

Symmetry: [Symmetrical / Asymmetry notes]
Aging changes: [Brow ptosis, lid laxity, jowls, neck bands]
Nasal analysis: [Dorsum, tip projection, airway]

Breast (if applicable):

Volume: [Assessment]
Ptosis: Grade I / II / III / Pseudoptosis
Asymmetry: [Description]
Masses: [Palpable masses / None]

Body Contour (if applicable):

Fat distribution: [Localized deposits]
Skin laxity: [Degree and location]
Musculature: [Diastasis recti check]

Assessment

1) [Diagnosis 1 - e.g., Acquired deformity of nose, Breast ptosis]

ICD-10: [Code]

2) [Diagnosis 2]

Surgical Candidacy: Good candidate / Moderate risk / Poor candidate Expectations: Realistic / Unrealistic

Plan

Recommended Procedure:

Options discussed: [List options]
Selected plan: [Specific procedure]

Pre-operative Instructions:

Smoking cessation required: Yes / No
Medical clearance needed: Yes / No
Lab work: [CBC, BMP, Coags, HCG]

Risks and Complications Discussed:

Infection, bleeding, scarring, asymmetry, need for revision, anesthesia risks.
[Procedure specific risks]

Photography:

Pre-operative photos taken: Yes / No
Consent for use obtained: Yes / No

Follow-up:

Schedule surgery / Return for second consult / Pre-op visit

Plastic Surgery — New Patient Consultation Template

Template