Coding for Flat Closure

… a project of

Support Providers with a Standard Coding Protocol for Aesthetic Flat Closure

Coding for aesthetic flat closure, whether at the initial surgery or at revision… 1430X if involving tissue rearrangement, 1310X if not

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Introduction

Our goal at NPOAS is to break down every barrier that women going flat face when trying to achieve an aesthetic result they can live with. One of these barriers is the lack of a standard insurance coding protocol for aesthetic flat closure and revision (chest wall reconstruction) services.

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

CodeProcedure DescriptionRVUNotes
1430X“tissue rearrangement” – adjacent tissue transfer (example: V-Y plasty)6.37For contouring with tissue rearrangement, both initial surgery and revision
1310X“scar revision” – repair, unusual, complicated3.50For contouring without tissue rearrangement, both initial surgery and revision
1577XFat grafting6.73
2.50
At revision, not initial surgery
19499Unlisted procedure, breastvariableLikely to be initially denied by insurance
15839Excision, excessive skin and subcutaneous tissue (includes lipectomy)10.50Likely 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!

June 20, 2020 – National Cancer Institute defines “aesthetic flat closure” as a unique reconstructive procedure.

April 19, 2020 – The Oncoplastic Breast Consortium adds “optimal flat closure” to its mission.

April 20, 2020H.686 Factsheet now available for download.

Feb. 26, 2020 – The largest health insurance company in Vermont, Blue Cross Blue Shield, now supports the revision bill

Feb. 20, 2020 – The Vermont Department of Financial Regulation issues a Consumer Alert asking anyone in the state who has experienced post-mastectomy revision denials to contact the department at 833-DFR-HOTLINE or dfr.insuranceinfo@vermont.gov

Jan. 20, 2020 – New patient survey! Did you need revision surgery after going flat? We want to hear from you! Help us ensure women’s access to care by filling out our short online survey

Jan. 12, 2020 – Vermont State Representative Charen Fegard introduces an historic bill requiring stakeholders to produce a standard reimbursement and coding protocol for revision surgery.

How You Can Help

1. Take action in your state – petition your representative(s) to introduce flat closure legislation modeled on the recent Vermont bill. Visit the legislative project page or send us a message to learn more!
2. Share your story or expertise!

Patients

Did you have (or ask for) revision surgery? Take the survey!

Providers

Are you a medical professional who has experience with coding for flat closure or revision services and want to share your insight? We would love to hear from you!

3. Donate to support our work.

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