Medical Billers Surgical Disclosure Notice

Beneficiaries must be notified in writing  of the expected out-of-pocket expenses related to an elective surgery that is not covered by their insurance over the amount of $500.  The disclosure is required to be given by surgeons and assistants.

For the purposes of the Federal Medicare program an “elective” surgery is one where:

  • It is scheduled in advance
  • It’s not an emergency surgery
  • If there was a delay in the procedure, it would not result in the patient death or permanent impairment.

Medical Billers Surgical Disclosure Notice

The OBRA at of 1986 (Omnibus Budget Reconciliation Act) mandates that the following information be included in the surgical disclosure notice in writing to the patient:

  • Estimated actual charges for the surgical procedure
  • Estimated Medicare payment
  • How much more it will cost over the approved charges
  • Any applicable coinsurance amounts
  • Beneficiary (Patient) out-of-pocket amounts.

Non-participating provider surgeons need to get this notice signed and dated by the patient before doing the procedure. A copy of the document should, of course, be maintained in the patient file. The MAC may request ask to see it.  If a non-par provider fails to properly notify the patient (beneficiary) before the procedure, any money paid by the beneficiary that exceeds Medicare-approved amounts will have to be refunded. Failure to do the refund can result in civil action and penalties from Medicare.

Here is what a sample Surgical Disclosure Notice looks like:

Name of Clinic —- Address —– Phone Number

Name of Beneficiary:____________________         Date:_________________

Type of Surgery/Procedure:_______________

Name of Provider__________________

Estimated charges___________________

Estimated Medical Payment Amount:____________________

Patient’s estimated payment including coinsurance amount:________________



_______________________                                 ___________________________

Signature of Medicare Beneficiary/Date                      Signature of Provider/ Date


When working with surgical disclosure notices always keep a copy on file. ALWAYS authorize  insurance and payment information and make sure as a medical biller that YOU understand what is going to be covered, what is not, and why? Make sure you have a clear understanding of what is elective surgery and what is not.


By: Dawn Moreno, PhD, CPC, CBCS, CMAA, MTC. Lives in the beautiful Southwest United States and has been an instructor for medical coding/billing for the past 7 years.  Interested in quality medical billing training? 

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Medical Billers Surgical Disclosure

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