Plastic and reconstructive surgery assessing rules in Medicare 011-42060070

Medicare benefits may be payable for plastic and reconstructive surgery services when they are clinically relevant or performed for a therapeutic purpose. This means the service is intended to treat, repair or improve a medical condition or functional issue.

These services are listed in the MBS under:

• Category 3 - Therapeutic Procedures
• Group T8 - Surgical Operations
• Subgroup 13 - Plastic and Reconstructive Surgery

This subgroup includes procedures that repair, restore or reconstruct tissue, skin, bone, breast, facial structures and nerves.

Services include, but are not limited to:

• correction of developmental breast abnormalities:
  • including surgery to correct breast development issues present from birth or that become apparent during development
• skin grafting and scar revision:
  • including skin graft repairs, treatment of wounds or defects, and surgery to improve or revise scarring
• breast reconstruction:
  • including reconstruction following mastectomy, trauma, congenital conditions or other clinically relevant reasons
• flap and microvascular reconstruction:
  • including skin flap repairs and complex tissue reconstruction
• orbital, facial and congenital reconstruction:
  • including reconstruction of the eye socket or face and surgery for conditions present from birth
• burns surgery:
  • including surgical treatment, repair or reconstruction of skin and tissue affected by burns
• jaw and craniofacial surgery:
  • including surgery involving the jaw, skull, face or facial bones
• surgery involving nerves or blood vessels in the neck, shoulder, upper chest or arm:
  • including procedures for thoracic outlet or brachial plexus conditions

Items may cover a range of plastic and reconstructive surgery services. Some are less complex, such as skin grafts or scar revision, while others involve more complex services such as microsurgery, free tissue transfer, burns reconstruction or nerve reconstruction.

Medicare benefits are not payable for surgical procedures performed mainly for cosmetic reasons, see Cosmetic plastic and reconstructive surgery.

When assessing claims for plastic and reconstructive surgery services, service officers must check the relevant MBS item description, item-specific requirements and any associated assessing rules.

Depending on the item, this may include checking:

• the area of the body treated
• whether the procedure was unilateral or bilateral
• whether the service involved one surgeon or conjoint surgery
• any same occasion or associated service restrictions
• whether the claim includes required text or notation

The item must meet the relevant MBS item description and any item-specific requirements before a Medicare benefit is paid.

Medicare benefits are not payable for procedures performed mainly for cosmetic reasons, including:

• face lifts
• eyelid reductions
• breast implants
• abdominoplasty, commonly known as a tummy tuck
• liposuction
• rhinoplasty or nose reshaping
• hair transplants

Medicare benefits may be payable for certain services when performed for specific medical reasons and the relevant MBS item requirements are met.

If the cosmetic procedure does not attract a Medicare benefit, benefits are also not payable for:

• assistance provided at the operation
• administration of the anaesthetic (including pre-operative examination)
• initial or subsequent consultations relating entirely to assessment or discussion of cosmetic services

Pre-surgery services, such as consultations only attract a Medicare benefit if they are clinically relevant services as defined in the Health Insurance Act 1973.

It is the responsibility of the health professional to determine whether a service can be billed to Medicare. They must consider:

• the clinical needs of their patient, and
• any provisions of relevant Commonwealth, State and Territory laws

Health professionals must make sure each service billed to Medicare meets:

• the MBS item description
• all eligibility requirements

A skin graft is an operation where skin is taken from another area of the patient's body, or in some cases from another person, and grafted to a wound or defect.

The removal of skin from another area of the patient's body or from a donor is included in the Medicare benefit for the graft and does not attract an additional Medicare benefit.

For grafts, elective dissection means preparing the skin at the site where the graft will be applied. This may include debridement, which is the removal of dead, infected or damaged tissue, and cleaning of the wound. It does not include the prior excision of a lesion. If a tumour, cyst, or similar lesion is removed before the graft, a Medicare benefit may also be payable under the appropriate item for that removal.

Items 45200 to 45207 cover skin flap repairs. Skin flap repairs are commonly used to cover a deep or large open wound, or to repair damaged skin.

Items 46100 to 46136 cover burns procedures. Burns items are used for excision and closure of burn treatment. Where separate items apply for excision and closure, service officers must check whether a modifier item also applies.

Items 82226 and 82227 cover dressing of burns when performed by eligible participating nurse practitioners.

See Skin services in the Medicare Benefits Schedule (MBS) for more details.

Specific items are available for breast reconstruction and breast excision services.

Some items have bilateral and unilateral versions to reflect whether one or both breasts are treated at the same time.

See External Breast Prostheses Reimbursement Program (EBPRP) for details about claiming reimbursement for non-surgical breast prostheses.

Nurse practitioner services

Item 82228 applies when eligible nurse practitioners perform intradermal colouration of the nipple or areola, or both, for:

• breast reconstruction following mastectomy
• congenital absence of the nipple

Intradermal colouration is a procedure that adds colour into the skin to recreate or improve the appearance of the nipple or areola.

See MBS Online for more details about eligible nurse practitioner services.

Items 45617 and 45620 are for the reduction of skin from the eyelids.

Full clinical details must be recorded in the patient notes, including clear photographic evidence that the eyelid skin falls over the lashes in a relaxed straight-ahead gaze and causes visual field obstruction. The clinical need for the service must be documented, as the claim may be subject to audit. MBS note TN.8.103 has more details about items 45617 and 45620.

General assessing rules for these services include:

• if the procedure is performed on one eye for medical reasons, Medicare benefits may be payable for the other eye to restore balance
• these items are payable twice on the same day if the claim includes text indicating both the left and right eye were treated

The Resources page contains:

• a link to MBS explanatory note TN.8.103
• frequently asked questions (FAQ) about reduction of eyelids

Items 45632 to 45644 and 45650 are for rhinoplasty services. Medicare benefits are not payable for rhinoplasty performed mainly for cosmetic reasons.

A Medicare benefit may be payable for rhinoplasty under these items when the surgery is for:

• airway obstruction, where the patient has a self-reported NOSE Scale score greater than 45
• significant acquired, congenital or developmental deformity

Septoplasty to correct the nasal septum under item 41671 may also be payable when performed with rhinoplasty.

The NOSE Scale is the Nasal Obstruction Symptom Evaluation Scale. It is used to assess nasal obstruction symptoms.

Full clinical details must be recorded in the patient notes. This may include pre-operative photographic evidence and/or NOSE Scale evidence demonstrating the clinical need for the service. The claim may be subject to audit.

The Resources page contains a link to MBS note TN.8.104 which has more details about rhinoplasty services.

Items 45677 to 45713 are for plastic and reconstructive surgery for cleft and craniofacial conditions. Health professionals must make sure the service meets the item description and is clinically relevant.

See Cleft and craniofacial conditions in Medicare for more details.