Plastic surgery billing runs two businesses at once. Reconstructive work is billed to insurance. Cosmetic work is paid by the patient. The same procedure can be either one, and the chart decides which. This guide covers the codes, what Medicare pays for them in 2026, the prior authorization rules, and the mistakes behind most denials.
The rates below are 2026 national Medicare amounts from the CMS fee schedule file. Your local rate will be a little higher or lower. You can check any code for your area in our Medicare fee lookup.
Cosmetic or Reconstructive? The Question That Decides Payment
Insurance pays when surgery restores function or fixes a problem caused by disease, injury or a birth defect. It does not pay for surgery done only to change how someone looks. The diagnosis code alone rarely settles it. The record has to show the problem before the surgery.
| Procedure | Usually covered when | Usually cosmetic when |
|---|---|---|
| Breast reduction (19318) | The record shows pain, skin problems or shoulder grooving, and the plan's tissue weight rules are met | It is done for size or shape only |
| Upper eyelid surgery (15822, 15823) | Visual field testing shows the eyelid blocks vision | It is done to look younger |
| Panniculectomy (15830) | Rashes or infections under the skin fold did not clear with treatment, and weight is stable | It is done for body shape (tummy tuck) |
| Nose surgery (30520, 30400) | Breathing is blocked. Septoplasty (30520) is the usual functional fix | It is done to change the shape of the nose |
| Breast reconstruction (19357, 19340, 19342) | After a mastectomy. Federal law (the Women's Health and Cancer Rights Act) makes most plans that cover mastectomy also cover reconstruction, including surgery on the other breast for symmetry | Not applicable |
Common Plastic Surgery Codes and What They Pay in 2026
For surgery done in a hospital or surgery center, the facility column is the surgeon's fee. The office column applies when the procedure is done in the office.
| Code | Procedure | Global days | Medicare 2026, facility | Medicare 2026, office |
|---|---|---|---|---|
| 19318 | Breast reduction | 90 | $980.32 | Not paid in office |
| 19357 | Tissue expander for breast reconstruction | 90 | $1,072.84 | Not paid in office |
| 19340 | Implant placed the same day as mastectomy | 90 | $701.08 | Not paid in office |
| 19342 | Implant placed later (delayed) | 90 | $694.40 | Not paid in office |
| 19350 | Nipple and areola reconstruction | 90 | $615.91 | $893.81 |
| 15823 | Upper eyelid surgery, heavy skin over the eye | 90 | $481.64 | $632.95 |
| 67904 | Droopy eyelid (ptosis) repair | 90 | $508.03 | $744.84 |
| 15830 | Panniculectomy | 90 | $1,067.16 | Not paid in office |
| 30520 | Septoplasty | 90 | $613.24 | Not paid in office |
| 14301 | Tissue rearrangement, 30.1 to 60 sq cm | 90 | $768.22 | $1,120.27 |
| 15100 | Split-thickness skin graft, first 100 sq cm | 90 | $660.34 | $922.53 |
| 13132 | Complex wound repair, 2.6 to 7.5 cm | 10 | $251.17 | $462.27 |
| 11042 | Wound debridement, first 20 sq cm | 0 | $55.78 | $132.60 |
Most reconstructive surgery has a 90-day global period. Follow-up visits for the same problem in those 90 days are part of the surgical fee and are not billed again. Our guide to the global period in medical billing explains what the package includes. Medicare marks 15830 and 30400 as “restricted coverage”, which means it pays them only when its coverage rules are met.
Prior Authorization: Medicare Now Asks for It Too
Most commercial plans need prior authorization for reconstructive surgery. Medicare does too, for some procedures:
- Hospital outpatient departments: since July 1, 2020, Medicare requires prior authorization for five types of service: blepharoplasty, rhinoplasty, panniculectomy, botulinum toxin injections and vein ablation.
- Ambulatory surgery centers: in 2026, CMS started a five-year demonstration for the same five services in 10 states: Arizona, California, Florida, Georgia, Maryland, New York, Ohio, Pennsylvania, Tennessee and Texas. For surgery centers the request is voluntary, but it gives you an answer before surgery instead of after.
For any payer, send the whole package before the case is booked: photos, measurements (such as tissue weight estimates for breast reduction or visual field results for eyelid surgery), the treatments already tried, and how long the problem has lasted. A missing photo found the week of surgery means a cancelled case or an unpaid one.
Modifiers Plastic Surgeons Use Most
| Modifier | When to use it |
|---|---|
| 50 | The same procedure on both sides, such as both upper eyelids |
| RT / LT | Right side or left side, when the payer wants two lines |
| E1 to E4 | Which eyelid: E1 upper left, E2 lower left, E3 upper right, E4 lower right |
| 51 | More than one procedure in the same session |
| 58 | A planned second stage during the global period, such as swapping a tissue expander for an implant |
| 78 | A return to the operating room for a problem caused by the first surgery |
| 79 | A new, unrelated procedure during the global period |
| GY | Medicare only: the service is excluded by law, such as cosmetic surgery |
The Denials Plastic Surgery Practices See Most
| Denial | Usual cause | Fix |
|---|---|---|
| CO-50 | The payer thinks the surgery was cosmetic | Appeal with photos, measurements and the payer's own criteria. |
| CO-197 | No prior authorization | Check whether a retro approval is allowed. Fix the scheduling step. |
| PR-204 | The plan excludes the service | Check the plan exclusions before surgery and collect as self-pay. |
| CO-97 | A code was bundled. For example, removing a lesion is included in a tissue rearrangement code | Do not bill the included code. Use a modifier only when the work was truly separate. |
| CO-4 | An eyelid or side modifier is missing or wrong | Add E1 to E4, RT/LT or 50 and resubmit. |
Billing a Case That Is Part Covered, Part Cosmetic
Take a septoplasty to fix breathing, done in the same surgery as a cosmetic change to the shape of the nose. Bill the septoplasty (30520) to insurance. Quote the cosmetic part as self-pay, in writing, before surgery. Split shared costs such as anesthesia and operating room time in a way you can explain. Never fold the cosmetic part into the insurance claim.
Cosmetic Self-Pay: Keep It Clean
- Collect payment or a deposit before surgery
- Get a signed financial agreement that says what is and is not covered
- Give the patient an itemized receipt
- For a Medicare patient, cosmetic surgery is excluded by law. If you send a claim at all, for example to get a denial for a second plan, add modifier GY
- Keep cosmetic and insurance revenue apart in your reports
When to Get Help
Most plastic surgery revenue is lost before the claim is sent: a weak prior authorization, a missing photo or a covered case that reads like a cosmetic one. Our plastic surgery billing services team builds the authorization package, codes the case and works the appeals for practices across the US. It starts with a free one-week audit of your recent claims.
Sources: CMS Physician Fee Schedule (2026 RVU file, conversion factor $33.4009), CMS Prior Authorization for Certain Hospital Outpatient Department Services, and the CMS ASC Prior Authorization Demonstration.
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