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Business Advisor
Getting Paid for Combined Surgery
Richard Vagley
Publish Date: December 14, 2007

As a plastic, primarily cosmetic surgeon, I often undertake cosmetic surgery in conjunction with non-cosmetic surgery on the same patient at the same time. A common example: bilateral breast reduction, which health insurers usually regard as medically necessary and therefore cover, and abdominoplasty, which health insurers rarely cover. Doing so can prove a little problematic. You're not only dealing with two payors — the patient's health insurer and the patient herself — but also, to some extent, a doubling of paperwork related to the documentation of surgery and surgical specimens. Here's advice for getting reimbursed for combined surgery. As you'll see, the key is to segregate the documentation of the procedures to avoid confusing the health insurer.

1. Perform the non-cosmetic surgery first. When you undertake cosmetic surgery in conjunction with non-cosmetic surgery, perform the non-cosmetic surgery first (unless contraindicated, as in the case of rhinoplasty/septoplasty, a "dirty" surgical procedure, bacteriologically speaking, in conjunction with a bilateral breast augmentation, a "clean" surgical procedure, bacteriologically speaking) so that it's positioned as the primary of the two surgical procedures. Here's why. In the event the health insurer in question ever examines the operative record, you want to be able to demonstrate that the non-cosmetic surgery is of primary importance (in other words, the primary reason for the surgery) and therefore was undertaken first. Also, the first hour of any surgical procedure is always the most expensive hour as the operative facility cost and anesthesia provider's fee are front-end loaded. In other words, the cost of preparation for surgery and disposables used at surgery are factored into that first hour. By undertaking the non-cosmetic surgery first, you shift the cost of that expensive first hour to the patient's health insurer, not to the patient.

2. Note start/stop times. Do so for each surgical procedure you perform, regardless of who's doing the surgery: the same surgeon (you), two surgeons undertaking unrelated surgery coincident with each other (you and another surgeon) or one after the other (you and another surgeon).

3. Dictate a separate operative report for each procedure you perform. In a sense, you want to treat each surgical procedure as a standalone surgical procedure, but it's a good idea to reference the other surgical procedure in the op report. For example, "after completing the bilateral breast reduction, I then initiated an abdominoplasty." Treating multiple surgical procedures undertaken at the same time upon the same patient as standalone surgical procedures, especially with regard to start/stop times, is particularly important when combining cosmetic and non-cosmetic surgery in order to deflect any contention from health insurers that the costs of the operative facility and anesthesia services related to the cosmetic surgery are hidden in the costs of the operative facility and anesthesia services related to the non-cosmetic surgery.

4. Consider the pathologist. Segregate surgical specimens to facilitate appropriate reporting of the examination of those specimens. Given most pathologists' tendency to proceed with both gross and microscopic examinations of any specimen handed to them, apply pre-printed, easily readable stickers to the specimens indicating gross examination only or gross and microscopic examination as the case may be, along with a request to generate a separate report for each specimen or related group of specimens, to insure that each operative report is mated with its corresponding pathology report. Obviously gross examination only is reserved for specimens related to cosmetic surgery since those specimens consist of perfectly normal tissue (such as skin and nasal bone and cartilage) for which I require — primarily for medico-legal reasons — an independent documentation of my removal of those tissues. And since the patient undergoing cosmetic surgery pays directly for pathology services related to cosmetic surgery-generated surgical specimens, minimizing those services by eliminating microscopic examination of those specimens saves the patient a few dollars.

Two birds, one stone
Combined surgery, which translates to two (or even more) payors and more (and more careful) recordkeeping, really isn't that uncommon, particularly given the inclination of many patients these days to address all of their surgical needs at one sitting in order to minimize post-operative downtime and absence from work for rest and recuperation.

I can recall more than a few patients of mine whose combined surgery necessitated the submission of insurance claims to two different third-party payors and, in one case, three different third-party payors. In that case, I undertook three surgical procedures, one of which his health insurer covered, another of which his workers' compensation insurer covered and the last of which his auto insurer covered. From time to time, I even undertake surgery upon patients who undergo other, unrelated surgery by other surgeons (most commonly, gynecologists and podiatrists) at the same time, again with the idea of killing two birds with the same stone. This advice has served me well in those situations.