Plastic and Reconstructive Surgery billing and accounts receivable

Every claim here answers one question first: was this reconstructive or cosmetic. The documentation that settles it has to exist before the operation, not after the denial.

Where the money leaks in plastic and reconstructive surgery

These are the recurring denial reasons in this specialty. They are not exotic. They are the ordinary ones that go unworked because the person who could fix them is at the front desk answering a phone.

• Functional impairment not documented, so a reconstructive procedure is read as cosmetic
• Prior authorization absent for a procedure the payer treats as elective
• Photographs or measurements required by the coverage policy not submitted
• Staged and related procedures inside the global period billed without the staging modifier
• Cosmetic portion not separated from the reconstructive portion on a combined case

What a seat does about it

One trained person works your queue from the difficult end. Every call is logged with the payer reference number and the outcome, so an appeal can quote what was said rather than start again. Denials are categorised, which is how the same reason stops coming back next month. On Friday you get it in writing.

The roles that matter most in this specialty are AR calling and denials at $1,700, prior authorization at $1,900, and certified coding at $2,500.

The codes those turn into

Each of these is a denial code you are likely to meet working plastic and reconstructive surgery, matched to the problem above it in your own words. The route back to payment differs by code, so a queue sorted by recovery route clears faster than one sorted by date.

• CO-197 — Prior authorization absent
  The payer required prior authorization for this service and cannot find one attached to the claim.
  Recovered by being taken back to the authorization. Matched from: “Prior authorization absent for a procedure the payer treats as elective”
• CO-22 — May be covered by another payer
  The payer thinks somebody else is primary. Until coordination of benefits is corrected on their file, nothing on this claim will pay.
  Recovered by being fixed at coordination of benefits and rebilled. Matched from: “Photographs or measurements required by the coverage policy not submitted”
• CO-16 — Claim lacks information
  Something on the claim is missing or malformed. On its own the code tells you nothing — the detail is in the remark code that comes with it.
  Recovered by being corrected and resubmitted. Matched from: “Staged and related procedures inside the global period billed without the staging modifier”

Working a denied claim costs $57.23 per denied claim in administrative time (source), and about about 90% of initially denied claims are eventually paid. Most of what sits in a plastic and reconstructive surgery AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

Questions