Whether or not a procedure is covered by a patient’s insurance plan is one of the biggest factors in determining how the billing process will take place. While covered procedures will go through the insurance carrier for reimbursement, non-covered procedures are the responsibility of the patient. So what happens when both types of procedure are performed during a single operation?

Consider a patient who must undergo a surgery to remove a series of small growths on her neck. Since she knows the physician will already be operating on that area, she also requests that he perform some basic plastic surgery to tighten her skin and remove a few wrinkles. Since this second procedure is cosmetic and not required, it would likely not be covered by a standard insurance plan.

What this means is that the coders and billers must prepare two separate reports, one for each service. While dividing the procedure codes for the operations themselves should be easy, the harder part will be splitting up the anesthesia and facility codes. In these cases, it is important that the operating physician provide extensive documentation regarding how much time and effort was put into each operation. The anesthesia should be measured by time and divided accordingly. After sending off the claim for the necessary procedure, be sure to bill the cosmetic operation directly to the patient.

While it may seem unnecessary, keeping covered and non-covered procedures on separate claims is essential to protecting patient privacy. If the insurance company is not going to pay for the cosmetic service, then they have no reason to know that it is even taking place. In fact, putting both operations on a single claim, even if the cosmetic procedure is something minor, would be a major violation of HIPAA.

As with many coding and billing matters, reporting simultaneous covered and non-covered procedures is a tricky matter that requires close attention to detail. If you are unsure whether or not different operations should be put on separate claims, always consult your manager so that you can protect your practice or facility from any potential liability.