Billing for reconstructive, cosmetic, breast and hand surgery practices, from solo aesthetic offices to hospital-affiliated groups.
A plastic surgery practice runs two revenue models on one schedule. Cosmetic cases are paid before surgery and never belong on a claim. Reconstructive cases pay well, $2,369.46 from Medicare in 2026 for a free flap breast reconstruction, but only when the authorization, laterality, staging modifier and medical necessity record line up. Missing or invalid prior authorization caused 17% of denials in our claim audit (Luxen claim audit), which is why prior authorization for reconstructive cases starts at scheduling.
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Plastic surgery billing services handle coding, prior authorization, claims, denials and patient billing for reconstructive and cosmetic surgery practices. The work keeps self-pay cosmetic cases off insurance claims and proves medical necessity before surgery. Medicare pays $1,072.84 nationally in 2026 for tissue expander placement, CPT 19357.
Plastic surgery billing changes with the mix of cash and insurance work each practice carries.
Service lines we bill: surgeon professional claims, office surgery suite and ambulatory surgery center facility claims, anesthesia on insured cases, and pathology on breast reduction specimens.
Most lost plastic surgery revenue sits in four repeatable scenarios. Dollar figures are 2026 Medicare national facility payments.
| Scenario | Codes | What goes wrong | $ at stake per claim | Luxen audit finding |
|---|---|---|---|---|
| Functional upper blepharoplasty, both eyes | 15823-50 | Visual fields do not show a 12 degree or 30% difference with the lids lifted | $722.46 (150% of $481.64) | Missing medical necessity documentation caused 31% of plastic surgery denials, across 4,600 plastic surgery claims |
| Bilateral breast reduction | 19318-50 | No tissue weight per breast or no pathology report | $1,470.48 (150% of $980.32) | 19% of denied claims were never reworked or appealed |
| Implant exchange after expanders | 11970 | Billed inside the 90-day global of 19357 without modifier 58 | $517.38 denied as global care | Staged procedures went out without modifier 58 on 12% of staged reconstruction claims |
| Panniculectomy with abdominoplasty | 15830 + 15847 | Authorization does not match the code performed, or symptoms not documented for 3 months of failed treatment | $1,067.16 (15830) | The payer authorized a different CPT code than the one performed on 8% of reconstructive cases |
Audit findings: Luxen claim audit and Luxen billing reviews.
Every covered plastic surgery claim turns on one question: does the record show a functional problem, or only appearance? The Medicare Benefit Policy Manual, Chapter 16, section 120 excludes cosmetic surgery except for prompt repair of an accidental injury or improving the function of a malformed body part. Severe burns, facial repair after a serious automobile accident and therapeutic surgery with a coincidental cosmetic effect stay covered. Commercial policies use the same split and add their own criteria.
| Procedure and code | What the policy asks for | Source |
|---|---|---|
| Upper blepharoplasty, 15822 or 15823 | Visual fields showing a 12 degree or 30% difference between resting lids and lids lifted by hand. Some contractors also require frontal and side photographs. | WPS LCD L34528; Palmetto LCD L34411 |
| Breast reduction, 19318 | Symptoms for at least 6 months, height and weight, prior treatments, tissue weight from each breast recorded in the operating room, pathology report and a breast-specific questionnaire. | Noridian LCD L35163; Article A57221 |
| Panniculectomy, 15830 | Pain, ulceration or intertrigo under the skin fold present at least 3 months and not responding to standard treatment. Photographs on request. | Noridian LCD L35163 |
| Abdominoplasty add-on, 15847 | Contractor-priced add-on to 15830 with no national Medicare amount. Confirm coverage in writing before surgery. | CMS 2026 fee schedule indicators |
When a covered and a cosmetic procedure share one operation, the claim carries only the covered code and its diagnosis, and the operative note documents each procedure separately. The cosmetic portion is quoted and collected as self-pay. Blending the two on one claim is how practices end up refunding a patient and repaying an insurer on the same case.
The Women's Health and Cancer Rights Act applies to group health plans and insurers that cover mastectomy. They must cover all stages of reconstruction of the breast removed, surgery and reconstruction of the other breast for symmetry, prostheses, and treatment of physical complications including lymphedema. Deductibles and coinsurance can apply, but no more than for other benefits. Medicare covers reconstruction of the affected and the opposite breast after a medically necessary mastectomy under NCD 140.2.
| Stage | CPT | 2026 national facility payment |
|---|---|---|
| Tissue expander placement | 19357 | $1,072.84 |
| Expander exchange for permanent implant | 11970 | $517.38 |
| Implant on the day of mastectomy | 19340 | $701.08 |
| Implant on a separate day from mastectomy | 19342 | $694.40 |
| Free flap reconstruction | 19364 | $2,369.46 |
| Single pedicle TRAM flap | 19367 | $1,559.15 |
| Latissimus dorsi flap | 19361 | $1,382.13 |
| Fat grafting, first 50 cc or less | 15771 | $473.62 |
| Nipple and areola reconstruction | 19350 | $615.91 |
| Revision of reconstructed breast | 19380 | $735.82 |
Every code in the table carries a 90-day global period.
Our certified medical coders check each stage against the one before it.
Nearly every reconstructive code carries a 90-day global period, which Medicare counts as 92 days: the day before surgery, the day of surgery and the 90 days after (CMS global surgery booklet MLN907166).
| Situation | Modifier | Medicare payment | Source |
|---|---|---|---|
| Additional procedures in the same session | 51 | 100% for the highest valued, 50% for each of the next four | Claims Processing Manual, Ch. 12, section 40.6 |
| Same procedure on both sides | 50, one line, 1 unit | 150% of the single-side amount | Section 40.7 |
| Co-surgeons on distinct parts of one procedure | 62 | 62.5% each | Section 40.8 |
| Physician assistant at surgery | 80 or 82 | 16% of the surgical amount | Section 20.4.3 |
| Nonphysician practitioner assisting | AS | 85% of the assistant amount, or 13.6% | Noridian assistant at surgery guidance |
Worked example: bilateral tissue expanders, 19357-50 on one line with 1 unit, pay 150% of $1,072.84, or $1,609.26 (Noridian bilateral surgery guidance).
Payers decide case by case. Noridian LCD L35163 wants breast reduction symptoms for at least 6 months, tissue weight from each breast and a pathology report. A gap costs the $980.32 Medicare payment for 19318. Missing medical necessity documentation caused 31% of plastic surgery denials (Luxen claim audit).
Blepharoplasty removes excess eyelid skin, coded by eyelid, such as H02.831 for the right upper lid. Ptosis repair is a different procedure, 67904. WPS LCD L34528 also requires a 12 degree or 30% visual field difference. The wrong pairing risks $481.64 per eyelid. Coding and modifier errors caused 21% of denials (Luxen claim audit).
For codes with bilateral indicator 1, Medicare wants one line with modifier 50 and 1 unit, paid at 150% (Claims Processing Manual, Chapter 12, section 40.7). For 11970 that is $776.07. Bilateral procedures went out without modifier 50 on 9% of bilateral breast claims (Luxen claim audit).
Placing the permanent implant inside the expander's global period is a staged procedure that needs modifier 58 (CMS Transmittal R11287CP). Without it, the $517.38 payment for 11970 is denied as global care. Staged procedures went out without modifier 58 on 12% of staged reconstruction claims (Luxen claim audit).
For denials already aging, denial and AR recovery works oldest money first. Appeals filed by Luxen were overturned 68% of the time (Luxen client data).
We run the revenue cycle from eligibility to zero balance inside the practice management system you already use. How full-service billing works.
Certified coders review charges against your documentation and payer rules before the claim goes out, so the denial is prevented rather than appealed. Medical coding.
Aged and denied claims are worked to resolution, then the upstream cause is fixed so the same claims stop coming back. Denials and AR recovery.
Benefits are verified and authorizations secured before the appointment, which is the cheapest place in the cycle to stop a denial. Eligibility and prior authorization.
Statements, balance questions and payment plans are handled by the same team that worked the claim. Patient billing.
Payer enrollment and re-credentialing are tracked through to approval, so a lapsed credential never quietly stops payment. Credentialing.
A HIPAA-trained front-office assistant working inside your EHR on calls, scheduling, intake and referrals, alongside the billing team. Medical virtual assistant.
Plastic surgery practices run on specialty systems that combine charting, clinical photography, quotes and cash payments: Nextech, ModMed, Symplast, PatientNow and Aesthetic Record, with athenahealth, eClinicalWorks and Epic common in hospital-affiliated groups. Many add photo documentation software whose images support medical necessity reviews.
We work inside the system you already have, with access granted after the BAA is signed. No migration. That matters: 38% had changed EHR or practice management system in the past five years (Luxen Practice Manager Survey 2026), and each switch resets templates, fee schedules and staff habits.
2 weeks
from a signed BAA to our team working your claims
About 3 weeks
to the first recovered payments on aged AR
20+ years
combined billing and coding experience
Cosmetic services and insurance-covered reconstructive care were moving through the same payment workflow. Luxen separated them before treatment, reducing rebilling and patient-refund cases by 71%.
Practice Manager, plastic and reconstructive surgery group
Staged reconstruction claims were difficult to track across authorization periods and surgical dates. Luxen created an episode-level review, recovered $84,600, and reduced average payment time from 76 days to 39.
Revenue Cycle Director, hospital-affiliated plastic surgery practice
Full engagements are written up in our dental practice case study and our ambulance billing case study.
Cosmetic surgery is paid by the patient, so federal estimate rules drive the front desk workflow.
| When the case is scheduled or requested | Estimate due |
|---|---|
| Scheduled at least 3 business days ahead | Within 1 business day of scheduling |
| Scheduled at least 10 business days ahead | Within 3 business days of scheduling |
| Patient asks for an estimate | Within 3 business days of the request |
Under 45 CFR 149.610, the estimate itemizes expected charges with service and diagnosis codes, it becomes part of the medical record, and patients can request copies from the last 6 years. A patient billed at least $400 more than the estimate can start patient-provider dispute resolution within 120 calendar days of the first bill (45 CFR 149.620). In December 2022, HHS extended enforcement discretion for estimates that leave out co-provider and co-facility charges, pending future rulemaking. No Good Faith Estimate was on file for 37% of self-pay cosmetic cases, across 21 plastic surgery practices reviewed (Luxen billing reviews). Deposits, refunds and estimates run through patient billing.
Indiana requires a requested estimate within 2 business days of receiving the patient's information, valid for 30 days, under Indiana Code 25-1-9.8-11 (medical billing rules in Indiana). In Virginia's out-of-network arbitration, plastic and reconstructive surgery made up 17.5% of 252 decisions in the 2024 to 2025 state report, averaging $11,882 per award (medical billing in Virginia).
3% to 6% of collections
Luxen's pricing generally falls between 3% and 6% of collections, depending on claim volume, specialty, payer mix, and how much of the revenue cycle your practice hands over.
Higher-volume practices usually land toward the lower end. Smaller or more complex practices land higher because there is more work per account. There is no setup fee and no exit fee, and the agreement runs month to month with 30 days notice.
A lower fee attached to weak billing is still expensive. The number that matters is what your collections do after you hire someone.
Luxen charges 3% to 6% of collections, month to month with 30 days notice, and no setup or exit fee. Example: a reconstructive and hand surgery practice collecting $140,000 a month from insurance.
| Service line | Monthly collections | Luxen at 3% | Luxen at 6% | In-house at 7.9% |
|---|---|---|---|---|
| Reconstructive surgery claims | $70,000 | $2,100 | $4,200 | $5,530 |
| Hand and trauma surgery | $25,000 | $750 | $1,500 | $1,975 |
| Office visits and minor procedures | $15,000 | $450 | $900 | $1,185 |
| Office surgery suite and ASC facility claims | $30,000 | $900 | $1,800 | $2,370 |
| Total | $140,000 | $4,200 | $8,400 | $11,060 |
Fully loaded in-house billing cost 7.9% of collections for practices under $2M, across 96 practices that shared payroll data (Luxen billing reviews), or $11,060 a month here. Even at 6%, Luxen costs $2,660 less each month. Your rate depends on claim volume and staged case mix.
Outsourcing pays off when staged reconstruction and prior authorization outgrow one biller, or that biller leaves. Open biller roles took a median 67 days to fill, and 42% of practice managers said nobody owns denial follow-up full time (Luxen Practice Manager Survey 2026).
| Partner type | Cosmetic and covered split | Staged case and global tracking | Cost basis |
|---|---|---|---|
| In-house biller | Depends on one person's training | Manual, often in spreadsheets | Salary, benefits, software, turnover |
| Generalist billing company | Often handled like any other claim | Varies by account | Percentage or per claim |
| Specialty billing company | Usually part of intake | Usually tracked | Percentage of collections |
| EHR vendor RCM | Tied to that vendor's software | Rules engine plus vendor staff | Percentage plus software contract |
| Luxen | Checked at scheduling, inside your existing system | Stage-by-stage review against each global period | 3% to 6% of collections, month to month |
Still weighing options? Compare medical billing companies by state, or see what full-service medical billing covers.
A 30-minute look at your AR ageing, denial reasons and payer mix. You leave knowing what is recoverable, what we would work first and what it would cost.
We sign a business associate agreement before anyone touches your system. Your named team then works inside the practice management system and clearinghouse you already use. Nothing is migrated, and claims are being worked within two weeks of the signed BAA.
Aged and denied claims come first because that is revenue you have already earned. Most practices see the first recovered payments inside three weeks.
Once the backlog is moving, we take over the agreed part of the daily cycle: eligibility, coding review, submission, posting, denials and patient balances.
You know who owns your claims. The team works inside the practice management system and EHR you already run, with no migration.
Claims are coded by certified coders against your documentation and payer rules. Automation handles the repetitive checks so people spend their time on the claims that need judgment.
We sign a business associate agreement before accessing protected health information, and access is limited to the named people on your account.
We look at your AR ageing, volume, payer mix and denial profile first, then tell you what we believe is recoverable and what it would cost.
A billing company is a poor fit if you are not willing to share visibility into your billing, if the vendor uses a rotating pool of people who never learn your practice, or if it cannot explain why your claims are being denied. Be wary of anyone promising large collection increases before they have seen your AR ageing. The right partner makes your revenue cycle more visible, not less.
Only when the surgery is not purely cosmetic. IRS Publication 502 counts cosmetic surgery as a medical expense only when it corrects a deformity from a congenital abnormality, trauma or disfiguring disease, and HSA and health FSA reimbursement follows that rule. Elective cosmetic cases are paid with cash, card or financing.
Luxen charges 3% to 6% of collections, month to month, with no setup or exit fee. For a practice collecting $140,000 a month, that is $4,200 to $8,400. Fully loaded in-house billing cost 7.9% of collections for practices under $2M in our billing reviews.
About 2 weeks from a signed BAA to working claims, with first recovered payments in about 3 weeks. Median time from signed BAA to first claims worked was 9 business days. Open staged reconstruction cases are mapped first, so no implant exchange misses its modifier 58.
Yes. Luxen works inside the EHR and practice management system you already use, including Nextech, ModMed, Symplast and PatientNow, with access granted after the BAA is signed. Nothing is migrated.
The claim carries only the covered procedure and its diagnosis, with the operative note documenting each procedure separately. The cosmetic portion is collected from the patient, with a Good Faith Estimate due within 1 business day when surgery is scheduled at least 3 business days ahead. Medicare excludes it under Benefit Policy Manual Chapter 16, section 120.
Thirty minutes, no deck and no fee. We look at what is sitting past 90 days and where your denials cluster, and you leave knowing what is recoverable, what we would work first, and what it would cost.
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