Medicare Codes Plastic Surgery Definitions Criteria And Rebates
The Medicare Benefits Schedule refers to a list of the medical services for which the Australian Government will provide a Medicare rebate to assist patients financially with the costs of their medical services. It determines the set rebate amounts that the Australian government will pay for medical services or procedures and are identified through item numbers. This schedule does not include all medical procedures, and the procedures which are included have a strict set of criteria to ensure only applicable procedures qualify for a rebate.
Who Decides If I Meet The Medicare Criteria
If you are embarking upon plastic surgery for a recognised medical purpose, the first step is to obtain a referral letter from your family GP to go and see a specialist. In order to be covered by Medicare, you need to ensure that the specialist youre referred a RACS Surgeon, preferably an accredited plastic surgeon with the Australian Society of Plastic Surgeons
Plastic Surgeons and Cosmetic Surgeons are NOT the same! Even though they sound similar they are different- and this makes a big difference when it comes to Medicare. Medicare and your Health Fund will only cover you if you approach a fully-trained and qualified accredited surgeon, not just a cosmetic doctor.
What Medical Procedures Are Covered By Medicare
Traditional or Original Medicare covers medically necessary surgeries, including any operations that will save your life. Your Original Medicare coverage also pays for surgeries that improve your health and quality of life.
Medicare covers emergency surgeries. For example, if you need immediate surgery for a life-threatening condition. Emergency operations might include heart surgery or an operation after a serious injury.
Medically necessary surgeries arent always emergencies. Original Medicare coverage includes operations you can schedule ahead of time. For example, joint replacement surgery or tumor removal are medically necessary operations that qualify for coverage.
If your doctor orders a medically necessary surgery, Medicare will help you pay the bill. Your Part A benefits cover inpatient surgery, and your Part B coverage pays for outpatient surgery. Part B also covers doctor services, lab tests, and other services you need while youre in the hospital.
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Obesity Screenings And Counseling
If your body mass index is 30 or over, then Medicare will bear the expense of your obesity screenings and behavioral counseling. These preventive services should be offered by your primary care physician or doctor in a doctors office or primary healthcare center.
Medicare will bear the cost of:
- Dietary assessment
- Obesity screening
- Nutrition counseling
Obesity screenings and behavioral counseling come under preventive services and are covered under Medicare Part B, which is a part of original Medicare. You might not have to pay anything out of your pockets as long as you meet the Medicare Part B deductible for the current year.
What Are Your Expectations
You are more likely to be happy with the results of cosmetic surgery if you have clear, realistic expectations and a clear understanding of why you want to have surgery. Your doctor can tell you if your goals are realistic and how best to achieve them.
Get the facts about what to expect from a certain procedure. Have your doctor show you photographs and explain the possible results. With some types of surgery, the final results may not appear for several weeks or months after the procedure. It may take several sessions or a combination of procedures to achieve the look you want. And results are not always permanent.
Remember that the effects of time, gravity, aging, and sun exposure continue after cosmetic surgery. Getting proper nutrition and regular exercise, guarding against sun exposure, managing stress, not smoking, and avoiding drugs and excess alcohol can go a long way toward helping you look and feel young and healthy.
Talking with someone who has had cosmetic surgery may raise issues that you had not considered. Ask how the person felt about the results, whether the surgery achieved the results hoped for, and what the total experience was like. Doctors who have experience with cosmetic surgery can also provide perspective on the issues involved.
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Medicare Changes And How Will They Impact On Your Plastic Surgery
Medicare have announced some significant changes to plastic surgery item numbers effective from 1 November 2018. Some item numbers are no longer included in the medicare benefits schedule while other item numbers now have very strict criteria to meet eligibility requirements.
What surgery is affected by the recent medicare changes?
The following are a list of plastic surgery procedures and medicare item numbers that have changed:
Breast lift Or Mastopexy Medicare Item No. 45558
For correction of Breast Sagging or drooping of the breast by breast lift or mastopexy the following Medicare criteria now apply :
at least two-thirds of the breast tissue, including the nipple, has to lie below to the infra-mammary fold. The nipple should also be located at the lowest part of the breast contour and
if the patient has been pregnantthe breast lift must be performed when the youngest child is more than 1 year but less than 7 years of age and
there must be photographic evidence demonstrating the need for this service.
Breast Reduction Medicare Item No. 45523
Reduction mammaplasty with repositioning of the areola and nipple:
for patients with large breasts and experiencing pain in the neck or shoulder region and
not with insertion of any prosthesis e.g. breast implant
In very particular or extraordinary circumstances a medicare and PHI rebate may apply only if:
it is demonstrated by intra-operative photographs that removal alone would cause unacceptable deformity or
Joint Replacements And Arthritis
Outside of cosmetics, the most common medically necessary procedures done relate to arthritis.
âWe deal with a lot of arthritis in joints, the hand, and the wrist,â Dr. Neumeister says. Surgeons often do joint replacements to remedy arthritis. Joint pain, swelling, and stiffness, especially in the fingers and hands, can be helped by a plastic surgeon.
Procedures like arthroplasty, arthroscopy, and synovectomy can help restore proper alignment and function in your joints. As long as the surgery is medically necessary, Medicare will pay its portion.
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What Is The Prior Authorization Process
Certain surgeries must now receive prior authorization before Medicare will cover associated costs.
In July 2020, the Centers for Medicare & Medicaid Services put prior authorization requirements in place for certain hospital outpatient procedures as a method for controlling unnecessary increases in the volume of these services.
The following outpatient surgeries now require prior authorization:
- Vein ablation
- Rhinoplasty
- Botulinum toxin injections
According to CMS, the goal of requiring prior authorization is to protect the Medicare Trust Funds from improper payments while still giving patients access to these surgeries for medically necessary reasons.
If prior authorization is not requested in advance for one of these procedures, it will not be covered by Medicare and you wont be able to appeal the decision.
Prior authorization involves sending medical records to Medicare.
A Medicare Administrative Contractor, or MAC, will then review the records and determine whether the procedure is medically necessary. A MAC is a private contractor who processes Medicare claims.
Prior authorization claims are usually processed within 10 days.
Before you undergo one of the outpatient procedures listed above, make sure to ask your doctor if prior authorization has been requested on your behalf.
Cosmetic Vs Plastic Surgery
Before we get into the nitty-gritty details of how the health insurance plans deal with these procedures, lets make one thing clear: cosmetic and plastic surgery are not the same thing.
That may surprise you, especially since many people use the two words interchangeably. Not that you can blame them. When cosmetic procedures first became common, everybody called them plastic.
Although its hard to say what caused that confusion, the most likely answer is a number of plastic surgeons at the time decided to focus on helping patients with cosmetic rather than reconstructive issues.
Today, people who work in these fields disciplines consider them very different beasts.
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Does Medicare Cover Blepharoplasty
Medicare covers upper eyelid surgery when the eyelid drops below the normal level, hindering sight. Also, if the cornea is swollen or if the skin relaxes excessively due to lack of elasticity.
Lower eyelid surgery is only available when the cornea is swollen. To get the coverage you must have a doctor record showing the visual disability, a field test must prove 30-degree blocking, and the doctor must take pre-op photos.
Functional Vs Cosmetic Plastic Surgery
Plastic surgery is divided into two categories:
Often, a procedure youâd think is purely for looks ââ¯like a facelift â can be done for medically necessary reasons. Understanding if surgery is cosmetic or functional is critical, especially regarding how much youâll pay.
All insurances â including Medicare, Medicare Supplements, and Medicare Advantage â will not cover cosmetic plastic surgery. If you want a cosmetic procedure done, youâll be paying out of pocket.
While it seems like the line between cosmetic and medically necessary could be blurry, Dr. Neumeister says thatâs not the case:
âWe get a detailed history from the patient explaining exactly why theyâre there to see us. The concern needs to be a functional impairment for us to even think about sending it to the insurance. It wouldnât be fair or honest for us to send it to insurance if we knew it really wasnât a medical problem.â
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Exclusions And Restrictions On Plastic And Reconstructive Surgery
Some health insurance policies give you full cover for the costs of most hospital admissions, apart from any excess or co-payment you agree to pay. Other policies restrict or exclude benefits for some treatments, in return for a lower premium:
Exclusions: you agree not to be covered at all for certain services. No benefits are payable for the excluded service by your health fund at all.
Restrictions: you agree to receive only limited benefits for certain services. This is usually enough to cover you as a private patient in a public hospital, but will leave you with large expenses if you are treated in a private hospital.
If your policy excludes or restricts Plastic and Reconstructive Surgery, this means there are over 1600 surgical procedures in the Medicare Schedule under the plastic and reconstructive category which your policy either does not cover or covers only to a limited extent. The procedures which you are not covered for can become clinically necessary at any stage of your life.
Why Must You Book A Consultation To Find Out The Price
Many surgeons want you to come in for a consultation to obtain pricing. This is perfectly reasonable, since not all gynaecomastia surgeries are the same. Some men have breast enlargement, a faulty breast gland and/or loose skin. Other men just want to reduce chest fat, but the gland is fine. Therefore, different surgical approaches may be used to address the patients desired cosmetic outcome.
Some male chest reduction procedures are more extensive than others. Gynaecomastia surgery is tailored to your needs. The final cost may differ based on the treatment plan you and your surgeon agree upon.
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Do Surgeons That Hide Prices Have Bad Motives
Not necessarily. As mentioned, your treatment plan is unique. The type of gynaecomastia surgery you need may affect the final price youll pay. Most surgeons want to see you in person so they can examine the chest. From there, they develop a surgical plan and provide you with an accurate price.
Since most men that see Doctor Bernard need gynaecomastia surgery with lipo and breast gland removal, his current surgery fee reflects this.
Does Medicare Cover Skin Removal Surgery
Dropping weight can have a downside such as rashes or infections from extra skin. If you suffer from excess skin after weight loss, Medicare covers skin removal. Excess skin removal may not be the stage of weight loss you foresaw however, insurance can help pay for the service.
For approval, you need to meet all of the following:
- Stable weight for 6-months before surgery
- A skin condition that threatens the health of your skin
- Excess skin that impacts daily movement
- BMI must drop at least 5 points
Medicare covers panniculectomy when its a medical need. This is the removal of the pannus. There is no rule to define cost or coverage prior to plastic surgery. In some cases, you pay first and get a reimbursement. Any serious need for the removal of skin has coverage. If excess skin makes your daily life tough, talk to your doctor.
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Facial Surgery Procedures Eye / Ear
42590 Canthoplasty, medial or lateral
45617 Upper eyelid, reduction of, if: the reduction is for any of the following: skin redundancy that causes a visual field defect or intertriginous inflammation of the eyelid herniation of orbital fat in exophthalmos facial nerve palsy post-traumatic scarring the restoration of symmetry of contralateral upper eyelid in respect of one of the conditions mentioned in subparagraphs to and photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes
45659 Correction of a congenital deformity of the ear if: the patient is less than 18 years of age and the deformity is characterised by an absence of the antihelical fold and/or large scapha and/or large concha and photographic evidence demonstrating the clinical need for this service is documented in the patient notes
Who Can Get Gender Reassignment Surgery
According to the American Society of Plastic Surgeons , gender reassignment surgeries have risks, such as bleeding, infection, poor healing of incisions, nerve injury and hematoma. There also risks associated with specific surgeries, such as injury to the urinary tract for transfeminine bottom surgeries. According to ASPS, good candidates for gender reassignment surgery:
- Have been diagnosed with persistent gender dysphoria
- Have two letters of recommendation from mental health professionals who support your decision to undergo surgery
- Have been living as a member of the opposite sex
- Have a positive outlook and realistic expectations
- Have reasonably well controlled medical or mental health concerns
Do you have more questions about Medicare coverage for people with gender dysphoria? Im happy to help. You can request information via email or schedule a phone call at your convenience by clicking one of the links. To see a list of plans in your area that you may qualify for, click the Compare Plans or Find Plans buttons.
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Choosing A Surgeon And Facility
Finding a cosmetic surgeon that you have confidence in and are comfortable talking to is extremely important when you are considering cosmetic surgery or procedures. You and your doctor can work together to build a treatment plan that both meets your needs and is realistic.
Consider the following things when you choose a cosmetic surgeon.
Cosmetic surgery is not an emergency procedure, so there is no reason to rush into it. Do not be pressured into making a quick decision. Get as much information as you need to feel comfortable about your decision. Don’t be afraid to get a second and even a third opinion, especially if you are not completely comfortable with your first doctor visit.
Current as of: March 3, 2021
Will Medicare Cover My Breast Reduction Surgery
There is significant research that indicates womens heavy, sagging & droopy breasts can cause neck pain, shoulder pain, rashes or infections and that these health concerns can be greatly relieved by breast reduction surgery . The following MBS codes apply:
- 45520
Reduction mammaplasty with surgical repositioning of nipple, in the context of breast cancer or developmental abnormality of the breast
- 45522
Reduction mammaplasty without surgical repositioning of the nipple:
excluding the treatment of gynaecomastia and
not with insertion of any prosthesis
- 45523
Reduction mammaplasty with surgical repositioning of the nipple:
for patients with macromastia and experiencing pain in the neck or shoulder region and
not with insertion of any prosthesis
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Does Medicare Cover Weight Loss Surgery
If you are morbidly obese, Medicare will cover some costs of weight loss surgeries.
These procedures are known as bariatric surgery, and they involve altering your digestive system to help you lose weight.
Bariatric surgical procedures include gastric bypass and laparoscopic banding surgery.
It can be difficult to estimate how much bariatric surgery may cost you. Its important to find out if youre an inpatient or outpatient.
Youll need to pay your deductible before Medicare pays anything. You may also owe copayments for the care you receive.
To qualify for Medicare-covered bariatric surgery, you must have:
- A body mass index of 35 or greater.
- At least one comorbid condition directly related to your obesity, such as sleep apnea or diabetes.
- Participated in a medically supervised weight loss program.
To be covered by Medicare, weight loss surgery must be performed at a facility that is certified by either the American College of Surgeons or the American Society for Bariatric Surgery.
Medicare will pay for abdominoplasty also known as a tummy tuck after weight loss surgery if it is deemed medically necessary because excess skin is causing rashes or infections.
How Can I Tell If A Surgeon Is Hiding Prices For Good Or Evil
Most surgeons dont list prices online. That is pretty standard. Many surgeons wont quote prices over the phone either. But if a surgeon wont provide a general price range, thats a red flag.
They should be able to give you a rough estimate of the prices they charge. For example, they could say, My average price range for gynaecomastia surgery is $4,000 to $6,000. Another surgeon might say, My surgeon fee is $6,000+. Its up to you to decide if the surgeons skills and qualifications warrant the price they charge. If they cannot provide a general price range over the phone, youll have to come in for a consultation to get a quote.
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