Most cosmetic plastic surgery involves surgical procedures that reshape, alter or augment the normal structures of the body in order to improve appearance and self-esteem. It is considered elective and not medically necessary when it comes to determining whether or not to use the root operation Alteration.

1. Most cosmetic plastic surgery involves surgical procedures that reshape,
alter or augment the normal structures of the body in order to improve
appearance and self-esteem. It is considered elective and not medically
necessary when it comes to determining whether or not to use the root
operation Alteration. The coder must peruse the medical record carefully
for the appropriate documentation. Some procedures, such as a rhinoplasty
can be performed for either medical or cosmetic reasons. If the procedure
is being done for medical reasons, the coder must use the appropriate root
operation (i.e., excision, bypass, repair, etc.) . Remember, the sole purpose
of the procedure is to improve the appearance when choosing the root
operation Alteration. The root operation Alteration is defined as
“modifying the anatomic structure of a body part without affecting the
function of the body part.”
Some common cosmetic procedures are:
Breast Augmentation
Body Contouring after Major Weight Loss
Liposuction
Tummy Tuck
Arm Lift
Rhinoplasty
Sclerotherapy
Gynecomastia Surgery
Facial Implants
Dermabrasion
Facelift Surgery
Eyelid Surgery
Neck Lift
Laser Hair Removal
Fat Transfer
Hair Replacement
Microdermabrasion Treatments
Purchase your copy of "The Basic How To...Coding Manual" .
COSMETIC SURGERY
WHAT TO EXPECT
1 Cosmetic Surgery
2 Root Operation Alteration
“0”
3 Why Code It Correctly?
4 Requests for Coding Topics
October 2015
Volume 2 Issue 10
By Cynthia Brown, MBA, RHIT, CCS
Gain Knowledge of Medical Coding Through E-Learning
CCHIS, P.O. Box 3019, Decatur, GA 30031 404-992-8984
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Cynthia@cyntcodinghealthinformationservices.com [phone]
CODING YESTERDAY’S NOMENCLATURE TODAY®
COSMETIC SURGERY
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2. Page 2 Coding Yesterday’s Nomenclature Today
The root operation Alteration, character value “0” is one of three root
operations categorized as root operations that include other objectives. The
objective of the root operation Alteration is to cosmetically enhance the
appearance of the body part of the patient for other than medical reasons.
Everything such as the approach, method, and devices used to meet this
objective are included in the root operation. Certain procedures however
can be performed for either cosmetic or medical reasons. As stated
previously, they require a medical root operation when deemed medically
necessary. For example, liposuction performed for medical reasons is
coded to the root operation extraction and breast reduction for medical
reasons is coded to the root operation excision. Below is the procedure
abdominoplasty which sometimes is referred to as a “tummy tuck” as it is
shown in the ICD-10 PCS Alphabetic Index:
Abdominoplasty
see Alteration, Abdominal Wall 0W0F
see Repair, Abdominal Wall 0WQF
see Supplement, Abdominal Wall 0WUF
As you can see there are several choices. If the surgeon’s documentation
does not state that the procedure is done for medical reasons, the coder
should query the physician. If the procedure is being performed by a plastic
surgeon or in a facility known for plastic surgery then of course the coder
should use 0W0F.
Section 0 Medical & Surgical
Body System W Anatomical Regions, General
Alteration 0 Alteration
Body Part Approach Device Qualifier
0 Head
2 Face
4 Upper Jaw
5 Lower Jaw
6 Neck
8 Chest Wall
F Abdominal Wall
K Upper Back
L Lower Back
M Perineum, Male
N Perineum, Female
0 Open
3 Percutaneous
4 Percutaneous
Endoscopic
7 Autologous Tissue
Substitute
J Synthetic Substitute
K Nonautologous Tissue
Substitute
Z No Device
Z No Device
Note: The coder should read the operative report carefully to ascertain the
type of approach and device used during the procedure. Remember to use
the anatomical regions body systems when there is not a particular body
part.
The ICD-10 PCS Medical & Surgical Section Reference Guide is an
excellent resource for understanding devices and their use.
Gain Knowledge of Medical Coding
“Abdominoplasty”
Certain procedures can be
performed for either cosmetic
or medical reasons.
Root Operation Alteration “0”

3. Coding Yesterday’s Nomenclature Today
Why Code It Correctly?
Some third party payors will not reimburse for cosmetic surgery therefore
the distinction between medical necessity and cosmetic elective surgery
must be documented and coded correctly. They have certain guidelines that
must be met or the provider risks the chance of being denied
reimbursement. For instance, guidelines for the procedures blepharoplasty
and brow ptosis repair for one third party payor are as follows:
Description: Blepharoplasty is a surgical procedure performed on the upper
and/or lower eyelids to remove or repair excess tissue that obstructs the
field of vision. It may also be performed for cosmetic purposes in the
absence of visual field obstruction. Brow ptosis (i.e., descent or droop of
the eyebrows) can also produce or contribute to functional visual
impairment.
Policy: Blepharoplasty and brow ptosis repair may be considered
MEDICALLY NECESSARY when performed for reconstructive purposes
when impairment of vision is documented.
The following visual field information must be provided as documentation
of visual impairment:
1. The indication for surgery is supported if a difference of 12º or more or
30% superior visual field difference is demonstrated between visual field
testing before and after manual elevation of the eyelids; OR 2. Visually
significant brow ptosis may be documented by visual field testing with the
brow elevated demonstrating a difference of 12º or more or 30% superior
visual field difference; AND 3. Visual fields need to meet accepted quality
standards, whether they are performed by Goldmann technique or by use of
a standardized automated technique. Visual fields are not necessary for
patients with an anophthalmic socket who are experiencing ptosis or
difficulty with their prosthesis.
For brow ptosis repair, photography should document the medical necessity
for brow ptosis repair (drooping of brows and improvement of
blepharoptosis or dermatochalasis/blepharochalasis by elevation of brows).
In addition, frontal photographs are necessary.
Blepharoplasty of the lower lids is considered COSMETIC.
Coverage: Pre-Certification/Pre-Authorization: Yes, ONLY for brow
ptosis repair.
CCHIS also has four e-books you may find useful The Basic How To..Coding Manual,
Coding Sepsis, Septicemia, SIRS, Severe Sepsis, and Septic Shock; ICD-10 PCS Medical
& Surgical Section Reference Guide; and ICD-9 CM & ICD-10 CM Obstetrics Coding .
Thank you in advance for your purchase(s).
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Trainer
ALL THINGS CODING®
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complete coding is a
must in today’s
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4. Page 4 Coding Yesterday’s Nomenclature Today
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