How medical recoding may limit options for breast reconstruction for cancer patients

The federal government is reconsidering a decision that breast cancer patients, plastic surgeons and members of Congress have protested would limit women\’s options for reconstructive surgery.

On June 1, the Centers for Medicare & Medicaid Services plans to review how doctors are paid for a type of breast reconstruction known as a DIEP flap, in which skin, fat and blood vessels are taken from a woman\’s abdomen to create a new breast.

The procedure offers potential advantages over implants and operations that take muscle from the abdomen. But it\’s also more expensive. If patients go out of an insurance network for the operation, it can cost more than $50,000. And, if insurers pay much less for the surgery as a result of the government\’s decision, some surgeons online will stop offering it, a group of plastic surgeons argued.

The DIEP flap controversy, highlighted by CBS News in January, illustrates the arcane and indirect ways the federal government can influence the medical options available, even for people with private insurance. Often the answers come down to billing codes — which identify specific medical services on the forms doctors file for reimbursement — and competing pleas from groups whose interests depend on them.

Medical coding is the backbone of \”how business is done in medicine,\” said Karen Joynt Maddox, a physician at Washington University School of Medicine in St. Louis who specializes in health economics and policy.

CMS, the agency that oversees Medicare and Medicaid, maintains a list of codes representing thousands of medical services and products. Regularly consider adding codes or reviewing or removing existing ones. Last year it decided to scrap a code that allowed doctors to raise significantly more money for DIEP flap operations than for simpler types of breast reconstruction.

In 2006, CMS established an \”S\” code — S2068 — for what was then a relatively new procedure: deep lower epigastric perforating flap or DIEP flap breast reconstructions. S codes temporarily fill gaps in a parallel system of billing codes known as CPT codes, maintained by the American Medical Association, a group of physicians.

The codes don\’t dictate the amounts private insurers pay for medical services; such reimbursements are usually negotiated between insurance companies and medical providers. However, using the narrow S code, doctors and hospitals have been able to distinguish DIEP flap surgeries, which require complex microsurgical skills, from other forms of breast reconstruction that take less time to perform and generally yield lower insurance payouts. .

CMS announced in 2022 that it would phase out the S-code at the end of 2024, a move some doctors say will dramatically reduce the amount surgeons get paid. (To be specific, CMS announced it would drop a set of three S-codes for similar procedures, but some of the more outspoken critics focused on one of them, S2068.) The agency\’s decision is already changing the landscape of surgery. reconstructive and creating anxiety for breast cancer patients.

Kate Getz, a single mother from Morton, Illinois, learned she had cancer in January at age 30. As she grappled with her diagnosis, she said, it was overwhelming to think about what her body would look like long-term. She imagined herself getting married one day and she wondered \”how the hell was I going to wear a wedding dress with only one breast left,\” she said.

She thought a DIEP flap was her best option and worried that she would have to have repeat surgeries if she got implants instead. Implants generally need to be replaced approximately every 10 years. But after spending more than a month trying to get answers about how her DIEP flap surgery would be covered, Getz\’s insurer, Cigna, informed her it would use a low-cost CPT code to reimburse her doctor. Getz said. As far as he could see, that would make it impossible for Getz to get the surgery.

Paying out of pocket \”wasn\’t even an option.\”

\”I\’m a single mom. We get by, right? But I\’m not, I\’m not rich at all,\” she said.

Cost is not necessarily the only hurdle patients seeking DIEP flaps must overcome. Citing the complexity of the procedure, Getz said, a local plastic surgeon told her it would be difficult for him to perform. She ended up traveling from Illinois to Texas for the surgery.

The government\’s plan to eliminate the three S-codes was spearheaded by the Blue Cross Blue Shield Association, a major lobbying organization for health insurance companies. In 2021, the group asked CMS to discontinue the codes, arguing they were no longer needed because the American Medical Association updated a CPT code to explicitly include DIEP flap surgery and related operations, according to a CMS filing.

For years, the American Medical Association has advised physicians that the CPT code was appropriate for DIEP flap procedures. But since the government\’s decision, at least two major insurance companies have told doctors they would no longer reimburse them under the highest-paying codes, prompting a backlash.

Physicians and breast cancer advocacy groups, such as the nonprofit organization Susan G. Komen, have argued that many plastic surgeons would stop providing DIEP flap procedures for privately insured women because they wouldn\’t get paid enough.

Lawmakers on both sides have asked the agency to keep Code S, including Rep. Debbie Wasserman Schultz (D-Fla.) and Sen. Amy Klobuchar (D-Minn.), who had breast cancer, and Sen. Marsha Blackburn (R-Tenn.).

CMS in its meeting of June 1 will evaluate whether to maintain the three S codes or delay their expiration.

In a May 30 statement, Blue Cross Blue Shield Association spokesperson Kelly Parsons reiterated the organization\’s view that \”there is no longer a need to maintain S-codes.\”

In a profit-driven health care system, there is a tug of war over reimbursements between providers and insurance companies, often at the expense of patients, said Joynt Maddox, a physician at Washington University.

\”We\’re in this sort of constant battle\” between hospital chains and insurance companies \”about who is going to wield more power at the negotiating table,\” Joynt Maddox said. \”And the clinical piece of that often gets lost, because it\’s often not clinical benefit, clinical priority, and patient-centricity that are at the heart of these conversations.\”

Elisabeth Potter, a plastic surgeon who specializes in DIEP flap surgeries, decided to perform Getz\’s surgery at whatever price Cigna would pay.

According to Fair Health, a nonprofit that provides information about health care costs, in Austin, Texas, where Potter is based, an insurer could pay an in-network doctor $9,323 for surgery when billed using code CPT and $18,037 under code S. These amounts are not averages; rather, Fair Health has estimated that 80% of payment rates are less than or equal to those amounts.

Potter said its Cigna reimbursement \”is significantly lower.\”

Weeks before her May surgery, Getz received big news: Cigna had reversed herself and would be covering her surgery with the S code. \”It felt like a real win,\” she said.

But he still fears for other patients.

“I\’m still asking these companies to do right by women,” Getz said. \”I\’m still asking them to provide the procedures we need to repay them at rates where women can access them regardless of their wealth.\”

In a statement for this article, Cigna spokeswoman Justine Sessions said the insurer remains \”committed to ensuring our customers have affordable coverage and access to the full range of breast reconstruction procedures and quality surgeons.\” who perform these complex surgeries.\”

The medical bills that health insurers typically cover are passed on to consumers in the form of premiums, deductibles, and other out-of-pocket expenses.

For any type of breast reconstruction, there are benefits, risks, and trade-offs. A 2018 article published in JAMA Surgery found that women who underwent DIEP flap surgery were more likely to develop \”reoperative complications\” within two years than those who received artificial implants. However, DIEP flaps were less likely to get infected than implants.

Implants carry risks of further surgery, pain, breakage, and even a rare type of immune system cancer.

Other flap procedures that take muscle from the abdomen can leave women with weakened abdominal walls and increase the risk of developing a hernia.

Academic research shows that insurance reimbursement affects which women are eligible for DIEP flap breast reconstruction, creating a two-tier system for private health insurance versus government programs such as Medicare and Medicaid. Private insurance generally pays doctors more than government coverage, and Medicare does not use S-codes.

Lynn Damitz, a physician and vice chair of the American Society of Plastic Surgeons\’ health and defense policy board, said the group supports continuing Code S temporarily or indefinitely. If reimbursements drop, some doctors will no longer do DIEP flaps, she said.

A study published in February found that, among patients who used their own tissue for breast reconstruction, privately insured patients were more likely than publicly insured patients to receive DIEP flap reconstruction.

For Potter, this shows what will happen if private insurance payments collapse. \”If you\’re a Medicare provider and you\’re not paid to do DIEP flaps, you never tell a patient it\’s an option. You\’re not going to do it,\” Potter said. \”If you take out private insurance and suddenly your reimbursement rate is reduced from $15,000 to $3,500, you\’re not going to have that surgery. And I\’m not saying it\’s the right thing to do, but that\’s what happens. \”

This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health policy research organization not affiliated with Kaiser Permanente.