Coding for Flat Closure

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

CodeCode DescriptorNotes (current RVU)
19499Unlisted procedure, breast.chest wall may or may not qualify as “breast” (variable RVU)
15839Excision, excessive skin and subcutaneous tissue (including lipectomy); other area.most revision involves removing excess tissue
(10.5 RVU)
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.

Shared Decision Making: Protecting Patient Autonomy and Informed Consent

SDM is about patient autonomy and informed consent.

Shared decision making (SDM) is a collaborative model of clinical decision-making that ensures the patient’s values and priorities are centered during the decision making process. It represents a philosophy of clinical practice that restores and protects patient autonomy and informed consent, and it is one of the avenues by which clinicians can achieve their goal of providing patient-centered care.

What is patient-centered care?

In patient-centered care, the individual patient’s specific health needs and desired health outcomes are the driving force behind all health care decisions and quality measurements. Providers consider the patient’s emotional, mental, spiritual, social, and financial needs while providing optimal clinical care.

The proximal outcomes—the patient feeling known, respected, involved, engaged, and knowledgeable—are desirable in and of themselves and may mitigate a patient’s distress associated with illness and uncertainty.

The Values and Value of Patient-Centered Care ,” Epstein et. al., 2011

According to the NEJM Catalyst, patient centered care produces the following benefits for both patients and providers:

  • Improved satisfaction scores among patients and their families
  • Enhanced reputation of providers among health care consumers
  • Better morale and productivity among clinicians and ancillary staff
  • Improved resource allocation
  • Reduced expenses and increased financial margins throughout the continuum of care

Why do we need SDM?

At its core, SDM is about returning agency to the patient in the healthcare decision making process against a historical backdrop of paternalism in medicine. In SDM, the process is truly shared between the patient and the provider – the patient brings their individual needs and preferences to the table, the provider brings their medical expertise, and together they come to an optimal decision. This optimal decision serves both the patient’s specific personal needs and preferences, AND their medical needs.

For mastectomy patients facing the reconstruction decision, SDM is critical to improving patient outcomes. A 2017 study out of Ohio State University found that less than half of patients undergoing mastectomy made a “high-quality” reconstructive decision that was consistent with their values and priorities. And one of the contributing factors was that patients were not adequately informed about their options. Clearly, there is room for improvement in the decision making process.

Patients who choose flat have different priorities

Multiple studies have confirmed that the population of patients who choose to go flat from the outset has distinctly different values and priorities that lead them to this path, vs. the population who chooses breast mound reconstruction (BMR). For women going flat, it’s absolutely critical that we not only have full information about our options, but that our preferences guide our decision making process.

Patients who choose FLAT

About 45% of patients.

  • want to avoid additional surgery
  • do not consider a breasted appearance to be important
  • worry about health impact of implants
  • tend to be older (over age 60, 4/5 choose flat)

Patients who choose BMR

About 55% of patients.

  • accept the possibility of additional surgery
  • want to maintain a breasted appearance to “feel whole”
  • do not want to use prosthetics
  • tend to be younger

It’s clear that for mastectomy patients facing the reconstruction decision, the “right choice” will be completely different for different individual patients.

“The ideal approach to breast reconstruction for one patient may not be the ideal for another. Individual circumstances, values, goals and preferences vary… every patient’s needs are different, and the right approach for breast reconstruction is not just about what is medically appropriate and reasonable.”

Dr. David T. Greenspun, Plastic & Reconstructive Surgeon

SDM has proven benefits

According to Dr. Minas Chrysopoulo of PRMA Plastic Surgery in San Antonio, multiple studies across several medical and surgical specialties have shown that shared decision-making yields many benefits when compared with the traditional “doctor knows best” process (from his 2017 Doximity article):

  • Improved patient education
  • Decreased patient anxiety
  • Decreased decisional conflict
  • Appropriate patient expectations
  • Improved patient satisfaction
  • Improved patient outcomes

Sounds great! How do we get there?

Implementing SDM: the SHARE model

The US Department of Health and Human Services has developed a user-friendly model for clinicians called the SHARE Approach: Essential Steps of Shared Decision Making (SDM). This model outlines five steps health care professionals can take to ensure that they are effectively implementing SDM with patients during clinical encounters. The steps were designed to incorporate the essential elements that have been defined for SDM.

From Dr. Minas Chrysopoulo’s 2017 Doximity artlcle, ” The Importance of Shared Decision Making in Breast Reconstruction”

Step 1: Seek your patient’s participation. Communicate that a choice (or choices) exist and encourage your patients to become involved in the conversation, while also being sensitive to the fact that under stress (as with a cancer diagnosis), some patients may need more direction than others.

Step 2: Help your patient explore and compare treatment options. This step is about ensuring the patient is fully informed, by discussing the benefits and risks of each option. Patients will receive and process this information in a way that centers their preferences, and can use the clinician’s guidance to ensure they understand the medical situation to the maximum extent possible for them.

Step 3: Assess your patient’s values and preferences. As the discussion progresses, the patient will express their assessment of each treatment option. The clinician assesses the patient’s understanding and support their process.

Step 4: Reach a decision with your patient. Collaborative decision making will involve the clinician listening to the patient, and the patient listening to the clinician, with give and take and an eventual decision arising from that process.

Step 5: Evaluate your patient’s decision. In a final review of the decision, the clinician evaluates the plan from a medical standpoint.

Watch Dr. Chrysopoulo’s presentation on SDM at ASPS 2018:

Decision Aids

The existing literature suggests that decision aids reduce decisional conflict, improve self-reported satisfaction with information, and improve perceived involvement in the decision-making process for women considering breast reconstruction (Berlin et. al., 2019).

The Dartmouth-Hitchcock Center for Shared Decision Making has a great list of resources for implementing SDM in clinical practice, including decision aids, toolkits, e-learning resources, and more.

Some examples of decision aids for breast reconstruction: BRECONDA, Breast Advocate, EMMI, Nurse BEDI, Patient +, Healthwise, Kaiser’s Breast Reconstruction Guidebook, MD Anderson’s Breast Reconstruction Options, University of Michigan’s Decision Guide.

A note on barriers to adopting SDM

According to the National Institute for Healthcare Reform, barriers do exist that slow the widespread adoption of SDM in clinical practice, including lack of reimbursement for physicians to adopt SDM under the existing fee-for-service payment system that rewards higher service volume, as well as several other concerns (NIHCR Policy Analysis No. 5, 2011).

Change isn’t easy, and every clinician has reasons for the way they operate. However, the general principle of keeping an open mind and considering the possible benefits of making a change definitely apply. The benefits for both patients and providers of SDM and patient centered care more generally are well characterized.

“There is no doubt that this approach [SDM] can increase emotional effort and at least initially, may prolong the length of consultations. However, as with a new surgical technique, familiarity improves comfort level and efficiency. Regardless of reimbursement model, improved patient outcomes and satisfaction can only help your practice.”

Dr. Minas Chrysopoulo

A note on language

“Shared decision making”… shouldn’t the decision belong to the patient? The term grates for some women, especially given the history of paternalism women have faced (and sometimes continue to face, unfortunately) when facing mastectomy.

“The rejection of medical paternalism in favor of respect for patient autonomy transformed the patient-physician relationship. Historically, medicine and society subscribed to the ethical norm that the physician’s main duty was to promote the patient’s welfare, even at the expense of the latter’s autonomy. A central assumption of the paternalistic framework was that physicians, because of their medical expertise, knew best what was in the best interest of patients. Accordingly, physicians decided which interventions would promote patients’ welfare; patients, for their part, were expected to comply.”

Kilbride et. al., ” The New Age of Patient Autonomy – Implications for the Patient-Physician Relationship” (2018)

SDM is about returning agency to the patient in the healthcare decision making process against this historical backdrop. The patient always retains “veto power” in medical situations (unless they’re declared incompetent, which is rare and a court ordered process). The right to refuse medical treatment is sacrosanct because consent is the foundation of all medical treatment – it’s what distinguishes consensual treatment from battery. In this sense, treatment decisions do belong solely to the patient.

Further reading

The Importance of Shared Decision Making in Breast Reconstruction (Chrysopoulo, Doximity article, 2017)

Shared Decision Making Necessary For Breast Reconstruction (Courtney Floyd, PRMA blog)

What Is Patient-Centered Care? (NEJM Catalyst, 2017)

Quality of Patient Decisions About Breast Reconstruction After Mastectomy (Lee et. al., 2017)

The SHARE Approach—Essential Steps of Shared Decisionmaking: Expanded Reference Guide with Sample Conversation Starters (AHRQ)

Feasibility and Efficacy of Decision Aids to Improve Decision Making for Postmastectomy Breast Reconstruction: A Systematic Review and Meta-analysis. (Berlin et. al. 2019)

Policy Options to Encourage Patient-Physician Shared Decision Making
NIHCR Policy Analysis No. 5

Stakeholders’ Perspectives on Postmastectomy Breast Reconstruction: Recognizing Ways to Improve Shared Decision Making (Hasak, 2017)

Helping Patients Make Better Treatment Choices with Decision Aids ( Hostetter & Klein, The Commonwealth Fund)

From informed consent to shared decision-making (Manyonga, Howarth, Dinwoodie & Nisselle, SAMJ Editorial, 2014)

SDM and Patient Centered Care Organizations



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Demand Parity for Flat Closure – Amend the WHCRA

A new project at Not Putting on a Shirt

Sign the petition or write a letter to your legislators!

What is the WHCRA?

The Women’s Health and Cancer Rights Act (WHCRA) is national legislation passed in 1998 which required most insurance companies to cover breast mound reconstruction (BMR) after mastectomy, surgery and reconstruction of the other breast to produce a symmetrical appearance, breast prostheses, and treatment of physical complications of the mastectomy. But there’s a catch.

What the WHCRA didn’t cover, was flat closure.

In the 1990’s, less than 20% of mastectomy patients elected BMR. Flat closure was the default, but it didn’t have a name – it was just “a mastectomy without reconstruction.”

Since there’s a near complete lack of data on patient satisfaction with flat closure aesthetics, we can’t say for sure whether flat closure quality has declined as BMR rates have soared – currently hovering at around half of all patients electing BMR. Certainly, anecdotal evidence would suggest that it has. But we do know that right now, at least 1/4 of women going flat are dissatisfied with their aesthetic result, and 1 in 20 are intentionally denied a flat closure.

We also know anecdotally that women frequently encounter insurance denials of coverage for flat closure and revision services. And we know that when insurance companies were denying coverage for BMR, patient advocates fought to pass the WHCRA… and that solved that problem.

The next step is obvious – amend the WHCRA to include coverage for flat closure and revision services!

Why do we need to amend the WHCRA?

To ensure insurance coverage for flat closure and revision services… so that women going flat don’t have to worry about fighting their insurance companies.

Aesthetic flat closure is not too much to ask.

Too often, if the option to go flat is mentioned at all in the surgical consult, it’s cast as a choice that’s “less than.” Most of the time, the idea of an aesthetic plastics closure isn’t even entertained for women going flat… whereas it is routine for women electing BMR.

In terms of getting revision surgery to achieve an aesthetic result they can live with, many women simply don’t have the ability to fight their insurance company during their recovery – so they are forced to live with a “mangled” chest. Whereas their sisters who choose breast reconstruction have their two, three, even up to nine or more surgeries covered by insurance without any suggestion that their surgeries are “cosmetic”.

Without corrective action, this disparity will endure.

The original intent of the WHCRA was to ensure that women facing breast cancer surgery were able to achieve aesthetic results they could live with. Who could have forseen that helping women who choose breast reconstruction would end up harming the rest who choose to go flat? Without corrective action, this disparity will endure.

Flat closure does not rebuild the shape of the breast, but it DOES correct a deformity caused by the mastectomy – it restores the normal anatomic contour of the chest wall (hence, “chest wall reconstruction”) – and therefore it is truly reconstructive (NOT cosmetic).

Our proposed amendment

It’s clear, from a reading of the WHCRA text, why flat closure is often interpreted as being excluded from coverage. However, this is an easy thing to fix – we simply need to change “breast” reconstruction in the legislation to “breast or chest wall” reconstruction. It’s that simple!

“… who elects either breast or chest wall reconstruction in connection with such mastectomy, coverage for— all stages of reconstruction of the breast or chest wall on which the mastectomy has been performed; surgery and reconstruction of the other breast or chest wall to produce a symmetrical appearance…”

Women’s Health and Cancer Rights Act of 1998

Amending the WHCRA is critical to ensure parity.

One in eight women will face a breast cancer diagnosis in their lifetime. And four out of five women over the age of 60 who have mastectomies, decide to go flat. That’s a lot of women potentially facing suboptimal care and additional hardship at one of the most vulnerable times in their lives.

Amending the WHCRA to include insurance coverage for flat closure (chest wall reconstruction) will be a critical step in ensuring these women receive the care they deserve.

Questions or Comments?

Tell us what you think.

Want to Help?

Sign the Petition or Write a Letter to Your Legislators!

Cleveland Clinic Researchers Publish Paper on Aesthetic Flat Closure

CREDIT: Djohan et. al. (The Breast Journal)
DOI: 10.1111/tbj.13641
You read that right. Cleveland Clinic researchers, in partnership with the University of Toledo, have been researching flat closure.
Cleveland Clinic y’all.

This week in research to #putflatonthemenu … a collaborative paper from researchers out of the The University of Toledo and Cleveland Clinic just published their aesthetic approach to flat closure in The Breast Journal, entitled “Technical considerations in nonreconstructive mastectomy patients”

“When performing post‐mastectomy closure without reconstruction, attention to tissue excess, medialization of axillary tissue and providing bulk with lateral and caudal tissue allows for an easy, reproducible, and aesthetic closure.”

– (Conclusion) Djohan et. al. 2019
What Does This Mean? We are Being Heard.

Beyond the technical impact of this research… the fact that researchers are actively pursuing this means that flat advocacy is making an impact. We are being heard. The medical community is realizing that women going flat expect better – we expect our choice to be honored, and we expect the same respect and consideration for our aesthetic result that women who choose breast mound recon are afforded.

Thank you, Cleveland Clinic researchers! Thank you for listening to women going flat, for taking our concerns seriously, and for putting your professional skills to use on our behalf.
Michelle Djohan MS
Rebecca Knackstedt MD, PhD
Tripp Leavitt MD
Risal Djohan MD
Stephen Grobmyer MD

Original version published on NPOAS’ Facebook page on October 27, 2019

FDA Issues Landmark Recommendations for Implant Manufacturers

Hot off the press – FDA is listening to women’s voices on breast implants. Today, FDA issued a recommendation to implant manufacturers that include many of the items that Breast Implant Safety Alliance and others have been pushing for:

  • a black box warning to clearly identify risks (this is the most serious warning labeling the FDA has in its toolkit)
  • a checklist to guide the patient-provider discussion
  • new screening guidelines for possible ruptures
  • clear ingredient information

This is about full disclose of a woman’s reconstructive options (this MUST include flat closure) as well as full information about the risks associated with each of those options. We applaud FDA for taking this important step and we extend our sincere gratitude to the explant advocates who have worked tirelessly at their own expense to be a voice for women on this issue.


Original version published on NPOAS’ Facebook page on October 23, 2019

NPOAS Will Have a Poster Presentation at SABCS 2019

Big news! NPOAS will be presenting a research poster at the San Antonio Breast Cancer Symposium this year, December 10th – 14th. The poster is entitled “Flat closure after mastectomy: are your patients satisfied with the results?”

This poster will weave together results from both of our ad-hoc surveys, and will be a springboard for encouraging researchers in the field to do larger-scale studies with validated tools.

We have our eye on the Breast-Q, an outstanding assessment tool developed by Dr. Andrea Pusic, the President of the Plastic Surgery Foundation, the nonprofit arm of the American Society of Plastic Surgeons (ASPS).

Learn more about our work.


Original version published on NPOAS’ Facebook page on October 20, 2019

Plastic Surgeons Are NOT Required to Discuss Aesthetic Flat Closure

It’s true… plastic surgeons are not required to discuss aesthetic flat closure during the reconstructive consult.
Christy Avila on International FLAT Day

Christy Avila of Fierce, Flat, Forward was just interviewed by patient safety watchdog blog MedTruth about going flat. Christy makes the excellent point that plastic surgeons are not required to discuss flat closure during the reconstructive consult – so oftentimes women don’t realize that going flat is even an option. She’s spot on! Click below to read the article.

What can we do about it?

NPOAS is addressing the problem of patients not receiving full disclosure of their options.

Late last year, we published “The Future of NPOAS” which outlined our strategic plan. This plan includes legislative and governmental initiatives to pursue systemic change to promote parity for flat closure, and one of the amendment targets is the NAPBC‘s plastic surgery reconstructive consult requirements protocol (see below).

Flat closure should be REQUIRED to be discussed alongside breast mound reconstructive options!

The National Accreditation Program for Breast Centers’ reconstruction consult requirements can be amended to include aesthetic flat closure at the fourth option.

Watch MedTruth’s interview with Breast Implant Safety Alliance‘s VP Julie Lykins:

Original version published on NPOAS’ Facebook page on October 18, 2019

Behind the Pink Ribbon Podcast with NPOAS Founder Kim Bowles

Now you can listen to NPOAS founder Kim Bowles’ interview with Behind the Pink Ribbon, a new breast cancer podcast by author Melissa Adams. Kim speaks about her diagnosis and treatment experience as well as her flat denial and advocacy work since.

Original version published on NPOAS’ Facebook page on October 17, 2019

Midwest Breast & Aesthetic Surgery Publishes Videos on Flat Closure

Flat closure to produce a smooth, breastless chest wall contour is a reconstructive procedure.

Listen to Dr. Pankaj Tiwari at Midwest Breast & Aesthetic Surgery discuss the issue on MWB’s YouTube channel:

Do you consider flat closure to be a reconstruction?

Should a plastic surgeon always be involved with a flat closure?

Thank you, Dr. Tiwari, for being a voice for women!

Original version published on NPOAS’ Facebook page on October 16, 2019

UCLA Researcher Launches Flat Closure Survey

We are so excited to share this news with our community. Dr. Deanna J. Attai, former President of the American Society of Breast Surgeons and breast cancer researcher at UCLA, has just launched her new study on flat closure! She is making history!

This is how we develop a standard of care for flat closure.

Thank you, Dr. Attai!


Original version published on NPOAS’ Facebook page on October 15, 2019

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