Cosmetic and plastic surgery assessing rules in Medicare 011-42060070

Medicare benefits do not apply to the following services for cosmetic reasons:

• face lifts
• eye-lid reductions
• breast implants
• tummy tucks
• liposuction
• nose jobs, or
• hair transplants

Note: benefits are payable for certain procedures when performed for specific medical reasons.

Where a claim for surgery performed for cosmetic reasons does not attract a benefit, the benefit is not payable for the following:

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

Services before surgery, for example, consultation services, only attract a Medicare benefit if that service meets the requirement of being a clinically relevant service as defined in the Health Insurance Act 1973.

It is the responsibility of the health professional to determine if 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 they bill Medicare:

• meets the MBS item descriptor, and
• eligibility requirements in full

Health professionals must apply to the Medicare Claims Review Panel (MCRP) for approval of payment of Medicare benefits for designated plastic surgery items if the date of service is before 1 November 2018.

These services can be identified by the statement ‘where it can be demonstrated’ in the item descriptor, see Medicare Claims Review Panel (MCRP).

Services for plastic and reconstructive surgery that are clinically relevant or for therapeutic purposes are found in the:

• MBS Category 3- therapeutic procedures
• Group T8 - surgical operations
• Subgroup 13 - plastic and reconstructive surgery

Item numbers in this subgroup include, but are not limited to:

• general plastic and reconstructive surgery
• skin flaps surgery
• burns procedures
• free grafts
• other grafts and miscellaneous procedures
• oral and maxillofacial surgery

A skin graft is an operation in which a strip of skin is excised from another area of the patient's body, or in some cases from another person, for grafting to a wound or defect.

The excision of the skin from another area of the patient's body or from the donor is covered by the benefit for the actual graft and does not attract an additional benefit.

Elective dissection, in relation to grafts, refers to the preparation of the skin at the site to which the graft is to be applied.

For example, debridement (removal of dead, infected or damaged tissue) and toilet (cleaning) of the wound. It does not refer to the prior excision of a lesion. Where there is prior removal of a tumour, cyst, etc., benefit is also payable under the appropriate item for the tumour or cyst 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. Separate items for excision and closure are covered by a modifier item.

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 excision items. Items were introduced to give patients better predictability on costs.

Some items now have bilateral versions as well as unilateral to reflect patients having both breasts treated at the same time, and to simplify billing for patients and providers.

See External Breast Prostheses Reimbursement Program (EBPRP) for non-surgical assistance.

Item 82228 is for:

• the intradermal colouration of the nipple or areola or both following breast reconstruction after mastectomy, or
• congenital absence of nipple when performed by eligible nurse practitioners.

See MBS-Online for more details on eligible services for Nurse Practitioner.

Items 45617 and 45620 are in Category 3, Therapeutic Procedures, Group T8, and Surgical Operations, Subgroup 13, Plastic and Reconstructive, Part 10 Operations of the MBS.

These items are for reduction of skin from the eyelids.

General assessing rules are:

• if the procedure is performed on one eye for medical reasons, Medicare benefits will be payable for a service performed on the other eye to return balance to both sides
• these items are payable twice on the same day if text is provided with the claim indicating left and right eye were both treated

The Resources page contains:

• a link to MBS explanatory note TN.8.103 for more information about items 45617 and 45620, and
• FAQ from staff

Items 45677 to 45713 are for plastic and reconstructive surgery for cleft and craniofacial conditions. Item numbers in this range can be billed even if the patient is not a prescribed dental patient under the Cleft Lip and Cleft Palate Scheme. However, health professional must make sure the service meets the item descriptor and is a clinically relevant service.

See Cleft and craniofacial conditions in Medicare for more details.