Interested in helping us break down barriers that women going flat face when trying to achieve an aesthetic result they can live with? Coding for flat closure is one of those barriers, and Not Putting on a Shirt is on the case with our Coding for Flat Closure project.
The problem: there’s no clear pathway to code for for flat closure and revision services. As a result, quite often providers will simply tell the patient they can’t or won’t do the procedure at all. So women are denied services and left with “mangled” chest walls while they’re dealing with breast cancer treatment.
Legislative action is one piece of the puzzle, but that will take some time… we need to support providers who offer these services, right now.
That’s why we are working to facilitate the development of a standard protocol, or pathway, for providers to seek reimbursement for flat closure and revision services… and that involves clearing up the confusion about CPT codes.
Background: what are CPT codes?
Current Procedural Terminology (CPT) is a medical code set maintained by the American Medical Association. It’s a common language for those who work in the medical field – each code is a unique string of numbers that indicates a service or procedure. In the breast surgery setting, CPT codes are used by providers to request reimbursement from insurance companies for the services they provide to their patients – lumpectomy, mastectomy, conventional breast reconstruction procedures, etc.
Here’s the catch: there are no CPT codes specific to flat closure or revision.
Without the proper coding, many insurance claims are denied… as too many women seeking revision surgery have discovered.
One solution to this problem might be to lobby for a new, unique CPT code. However, this becomes complicated very quickly. When you add a new CPT code to the mix, by definition any value assigned to it has to be taken away from an existing code – and that means that we might inadvertently worsen reimbursement for mastectomy itself. Not good!
So we are left with selecting a code from the existing list – but which one?
Reviewing the candidates
Our review has determined the following short list of options for coding for flat revision (note: “modifier -22” can be appended to the initial mastectomy code (19303) if the contouring work is done during the initial surgery.)
CPT Coding for Flat Closure Revision Surgery
|Code||Code Descriptor||Notes (current RVU)|
|19499||Unlisted procedure, breast.||chest wall may or may not qualify as “breast” (variable RVU)|
|15839||Excision, excessive skin and subcutaneous tissue (including lipectomy); other area.||most revision involves removing excess tissue|
|Repair, unusual, complicated, over 7.5 cm, any area / each additional 5cm or less||complex incision type wound repair (3.50 RVU)|
|adjacent tissue transfer (example: V-Y plasty)||exact code depends on surgical field size (6.37 RVU)|
Other considerations are procedure specifics, code valuation, and the status of a code as “unlisted”:
Procedure Specifics. The choice of code for any given revision procedure may depend on the details of exactly how the procedure was performed.
Valuation. Each CPT code is assigned a value by the AMA, called an “RVU” (Relative Value Unit). A higher RVU means a better reimbursement rate.
A note on “unlisted” procedure codes. Because these codes are non-specific, providers must submit supporting documentation so that billing can determine coverage and payment. This presents an additional burden on providers.
Learn more at the Coding for Flat Closure project page:
Not Putting on a Shirt will continue to work with stakeholders to produce a workable protocol for CPT coding for flat closure and revision services.
Want to help? Contact us below, or donate to support this project.
We welcome your input! If you’ve experienced (or struggled with) coding for flat closure or revision services, or if you have expertise in medical coding and want to share your insight, please send us a message. We’d love to talk to you.
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