Coding for Flat Closure

… a project of

Support Providers with a Standard Coding Protocol for Flat Closure

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 flat closure and revision (chest wall reconstruction) services.

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 flat closure or flat revision.

No Code = Big Problem

In the absence of a unique code, surgeons are left to “fill in the blank” when they try to bill insurance, and requests are frequently 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. Combine that with poor reimbursement RATES for most of the “fill in the blank codes” and you end up with a big financial disincentive for providers to offer these services.

That’s why so many patients seeking flat closure and revision services are told “that’s cosmetic, insurance won’t pay” or simply 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 are working to facilitate the development of a standard coding protocol for flat closure and revision services. Once the protocol is in place, 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 CPT code?

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. There are CPT codes for all sorts of breast surgical procedures… but of course, none specifically for 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 from the existing list – but which one?

Reviewing the candidates

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

What have we ruled out? All mastectomy related reconstruction codes currently fall under one specific section in CPT, the 19000’s. Code 19366 (breast reconstruction with other technique) would make sense if flat closure were defined as “breast reconstruction” – however, the NIH definition currently excludes anything other than breast mound procedures from that umbrella. Mammaplasty (reshaping or otherwise modifying the appearance of the breast) codes are unfortunately out as well because of the required goal of achieving a “clinically normal” sized breast target.

Candidate codes. Our review has narrowed down the current menu of options for coding for flat revision to the following (note: “modifier -22” can be appended to the initial mastectomy code (19303) if the chest wall contouring work is done during the initial surgery.)

CPT Coding for Flat Revision Surgery

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

Code*Code 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)
13101/
13102
Repair, unusual, complicated, over 7.5 cm, any area / each additional 5cm or less complex incision type wound repair (3.50 RVU)
14301/
14302
adjacent tissue transfer (example: V-Y plasty)exact code depends on surgical field size  (6.37 RVU)

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.

The American College of Surgeons also has a committee on coding, a page on breast surgery coding that we are lobbying to include a flat closure protocol, as well as a coding hotline for fellows of ACS. The American Society of Plastic Surgeons is also holding a plastic surgery coding workshop in New Orleans in 2020.

Stay tuned for project updates!

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. You can also donate to support our work.

REGISTERED CHARITY ID# 84-3021062

FAIR USE STATEMENT

This site contains copyrighted material. Not Putting on a Shirt’s educational materials and resources on this site are freely available for “fair use” (Title 17 U.S.C. Section 107) in accordance with our mission to advocate for optimal outcomes for those who choose to go flat after mastectomy.  The copyrighted material on this site is distributed for educational purposes without profit – all donations to Not Putting on a Shirt directly fund our advocacy work. If you wish to use copyrighted material from this site for purposes that go beyond “fair use”, you must first obtain explicit permission from the copyright owner. Please direct requests or questions to info@notputtingonashirt.org.

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