Coding for Flat Closure

Note: all specific references to CPT codes and descriptions are © 2018 American Medical Association

What is Medical Coding?

Medical coding is a type of system – a “language” – used for tracking and paying for healthcare services.

In the United States, health insurance companies usually foot most of the bill for breast cancer related surgeries. When a provider such as a breast or plastic surgeon performs a service (such as a mastectomy) for their patient, they bill the patient’s health insurance company in order to get paid for their work. The outcome of a reimbursement request (approval or denial, as well as rates) is mostly determined by the way in which the surgeon “writes up” the bill.

They do this write-up via medical coding. Each procedure the provider performs has a unique code associated with it that tells the insurance company exactly what the provider is asking to be reimbursed for. There is a code for simple mastectomy, a code for skin-sparing mastectomy, and a bunch of codes for different kinds of breast reconstruction.

But there is no unique code for aesthetic flat closure or flat revision. That’s partly because it’s a new term, and partly because achieving an aesthetic flat closure may involve more than one type of specific surgical procedure or technique.

The Problem: Coding Confusion

In the absence of a unique code or an agreed upon coding protocol, surgeons are left to “fill in the blank” when they try to bill insurance, and requests may be denied. If surgeons had unlimited time and resources, this wouldn’t be a problem. But the time that a surgeon (or their staff) spends trying to figure out a coding question, or dealing with billing and appealing insurance denials, costs them money. This may be why so many patients seeking aesthetic flat closure and revision services have been told “that’s cosmetic, insurance won’t pay” or have simply been sent out the door empty-handed.

Part of the solution to this problem is to amend the WHCRA to mandate insurance coverage for chest wall reconstruction alongside breast mound reconstruction – that will put a stop to claim denials. But legislative action takes time. We need to support providers who want to offer these services, right now.

That’s why we have worked with stakeholders to facilitate the development of a standard coding protocol for aesthetic flat closure and revision services. Once this protocol is agreed upon, advocates (and providers) can lobby for better reimbursement RATES for the code(s) used. Because when these procedures are fairly reimbursed, both access AND quality of aesthetic outcomes will improve.

Do We Need a NEW Code for Aesthetic Flat Closure?

The short answer is no. To understand why, we need to review how the system works.

The specific medical coding system we are concerned with is called Current Procedural Terminology, or CPT, and is maintained by the American Medical Association. Each code is a unique string of numbers that indicates a service or procedure (ex. modified radical mastectomy = 19307). There are CPT codes for all sorts of breast surgical procedures… but of course, none specifically for aesthetic flat closure or revision.

One solution to this problem might be to lobby for a new, unique CPT code. However, this becomes complicated very quickly. Because the CPT valuation pie is finite, when you add a new code to the mix, by definition any value assigned to it has to be taken away from an existing code. In our case, this means that we might inadvertently worsen reimbursement for mastectomy itself. Not good!

So we are left with selecting a code (or codes) from the existing list – but which one?

Reviewing the Candidates

Note: all specific references to CPT codes and descriptions are © 2018 American Medical Association

Candidate codes. Our review has narrowed down the current menu of options for coding for aesthetic flat closure to the following.

CPT Coding for Aesthetic Flat Closure

Code	Procedure Description	RVU	Notes
1430X	“tissue rearrangement” – adjacent tissue transfer (example: V-Y plasty)	6.37	For contouring with tissue rearrangement, both initial surgery and revision
1310X	“scar revision” – repair, unusual, complicated	3.50	For contouring without tissue rearrangement, both initial surgery and revision
1577X	Fat grafting	6.73 2.50	At revision, not initial surgery
19499	Unlisted procedure, breast	variable	Likely to be initially denied by insurance
15839	Excision, excessive skin and subcutaneous tissue (includes lipectomy)	10.50	Likely to be initially denied by insurance

Procedure Specifics. The choice of code(s) for any given surgery will depend on the details of exactly how the procedure was performed – in this case, if tissue rearrangement is involved or not, and if fat grafting is involved or not. Most aesthetic flat closure at the initial mastectomy will be coded as 1430X, because they typically involve a V-Y plasty or other tissue rearrangement.

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. Mastectomy codes (1930X) have RVU values of 15.00 – 18.23 which is much higher than any of the RVUs for aesthetic flat closure codes.

A note on “unlisted” procedure codes. Because these codes are non-specific, providers must submit supporting documentation so that the insurance company can determine coverage and payment. This presents an additional burden on providers, and insurance companies are likely to initially deny coverage.

The American College of Surgeons also has a committee on coding, a page on breast surgery coding that we are lobbying to include an aesthetic flat closure protocol, as well as a coding hotline for fellows of ACS.

Stay tuned for project updates!

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