Charging for Self-Pay Procedures: Sebs, Tags, and Nevi
Mark S. Nestor, MD, PhD
In dermatology, most individuals have “spots and growths”, such as seborrheic keratosis, milia, nevi and cysts that are cosmetically bothersome. The removal of these spots and growths isn’t considered medically necessary and therefore is not covered by insurance providers. In addition, Mark Nestor, MD, PhD, explained that preventative treatments, such as photodynamic therapy (PDT) for photoaging and photodamage is not a covered procedure in most insurance plans.
Dr. Nestor continued his presentation by reviewing the specific definitions of medically necessary and non-medically necessary procedures. Medically necessary procedures and treatments meet accepted standards of medicine that are both medically reasonable and necessary to benefit or improve the specific condition.
Non-medically necessary procedures are sometimes in a gray area, because removal of certain benign lesions may also fall under either category based on symptoms or clinical presentation. Removal of benign cysts is one example of a procedure that could be either medically necessary or non-medically necessary.
Next, Dr. Nestor encouraged practitioners that perform non-covered procedures to document the procedures accurately and to also use additional consent, waiver, and ABN forms to explain to patients, prior to proceeding with the procedure, why these procedures are non-medically necessary and not covered by their insurance provider. He also recommends using the ICD-10 code Z41.1.
Dr. Nestor reviewed a gray area in the treatment of seborrheic keratosis, which may be medically necessary to treat if it is suspicious for malignancy, symptomatic, or inflamed. If these criteria are not met, patients with these lesions can either pay the Medicare allowable or a self-pay amount to receive treatment, and Dr. Nestor reminds us that these claims should not be submitted to the insurance provider. Light and laser treatments for acne and laser treatments for onychomycosis are examples of effective treatments that are not covered by most insurance providers at this time.
Dr. Nestor concluded his discussion by emphasizing that patient education and counseling of the patient are key aspects in the non-medically necessary treatment plan. He reminds us to document non-covered procedures adequately and to utilize a separate consenting process. These procedures can add significantly to a busy dermatology practice.