This Simple Coding Change Could Kill Access to DIEP Flap Breast Reconstruction for Thousands of Americans
Changes in medical coding by the Centers for Medicare and Medicaid Services (CMS) will severely limit the breast reconstruction options women have available through insurance, potentially making procedures like the DIEP flap a viable choice only for the very wealthy.
“It’s Only Coding”
Until recently, DIEP flap breast reconstruction and other complex microsurgical breast reconstruction procedures (like the GAP flap, thigh flaps and stacked flaps) had unique billing codes, known as “S-codes”. These are specialized insurance codes that were created to allow US plastic surgeons to bill insurance plans for complex breast reconstruction procedures like the DIEP flap.
In 2019, CMS decided to combine all microsurgical breast reconstruction procedures that use the patient’s own tissue (knowns as “free flap” surgeries) together under one code. In January 2021, CMS made the further decision to eliminate the S-codes: sunsetting of these codes has been scheduled for December 31, 2024. Moving forward, surgeons performing a DIEP flap reconstruction will only be able to bill insurance plans using the same code (CPT 19364) as the free TRAM flap – a much older, more invasive surgery that sacrifices all the patient’s abdominal muscle(s), is associated with a longer recovery and increases the risk of long-term complications like abdominal weakness and hernias.
While breast reconstruction practices will still be able to offer the more modern procedures under the “catch-all” 19364 code, it is very likely some insurance carriers will use these coding changes to limit the procedures they cover, or cut reimbursement to the point where physicians can no longer offer them. This is actually already starting to play out: despite the S-codes still being in effect until December 31, 2024, their anticipated sunsetting has already led to some insurance plans declaring their intent to stop covering DIEP flap surgery. Between now and next year, multiple commercial health insurers will likely follow suit.
As a result, fewer patients will have access to DIEP flap surgery and other advanced microsurgical breast reconstruction options through insurance. The most likely outcome is that very soon, only the most wealthy of patients will have access to these advanced types of reconstructive surgery.
A Message From PRMA President, Dr. Chrysopoulo
“It is very important for patients to understand that the DIEP flap procedure, as well as the other advanced ‘natural’ tissue reconstruction options (eg PAP flap, LTP flap, etc), are not going away. These procedures are still available in the US and will continue to be performed by plastic surgeons in this country. Coding changes alone do not make surgeries defunct”, explains Dr Chrysopoulo.
“What is under threat due to the changes to code 19364 and the sunsetting of the S-codes is women’s access to these superior, natural options through their insurance, because of the way in which insurance companies are taking advantage of these coding changes. The Women’s Health Cancer Rights Act (WHCRA) of 1998 states that if you are receiving benefits in connection with a mastectomy and you elect to have breast reconstruction, coverage must be provided for your breast reconstruction, symmetry procedures of the remaining breast, and treatment of complications such as lymphedema. Your right to have breast reconstruction under WHCRA isn’t what’s under attack here; it’s your access to these advanced procedures through insurance that’s at stake. Ultimately, what good are your rights if you have no access? Unfortunately, the language in the WHCRA is dated and does not go far enough in protecting this access.”
“Along with our plastic surgery colleagues and passionate patient advocates across the country, we pledge to continue fighting these coding challenges to ensure our patients have the access they need to all their breast reconstruction options. PRMA will continue to serve our patients’ needs regardless of any coding changes“, says Dr Chrysopoulo.
What Can Patients Do
We strongly urge patients to use their voices! Please contact your senator or representative immediately: request they update and strengthen the language in WHCRA to ensure insurance companies will always provide full patient access to modern breast reconstruction, regardless of the codes used today, or in the future.
You can find a sample letter and contact information for your senator here.
“PRMA, as always, remains 100% committed to providing the full spectrum of advanced breast reconstruction options for our patients.”