New CMS Coding Shortchanges Natural-Tissue Breast Reconstruction

Until recently, deep inferior epigastric perforator (DIEP) flap breast reconstruction and other perforator flap breast reconstruction surgeries had unique procedure codes. In 2019, CMS decided to combine all flap breast reconstruction procedures together under one code and to phase out unique codes for individual flap procedures by December 31, 2024, according to Breastcancer.org.

Elisabeth Potter, MD, is a plastic surgeon in Austin, Texas, who specializes in DIEP flap breast reconstruction. In this video, she discusses how the CMS code change for breast reconstruction surgeries will shift physician reimbursement to lesser surgeries, forcing patients to choose to have a reconstruction that is more dangerous. Potter is certified by the American Board of Plastic Surgery (ABPS).

The following is a transcript of her remarks:

So breast reconstruction has been covered under the Women’s Health and Cancer Rights Act [WHCRA] since 1998. Breast reconstruction comes in a couple of different varieties: using an implant or using your own tissue.

The recent coding changes affect coverage for using your own tissue. Basically, the change equated all types of natural-tissue breast reconstruction together, even though they’re very different from the patient perspective. Unfortunately, when they equated them together, they devalued them to the value of the least desirable breast reconstruction.

The change in coding really changes the reimbursement to the physician. What we’re seeing is, obviously, if a surgeon can’t afford to offer a surgery because it’s too complex, then patients just don’t find the option. We’re also seeing another disturbing trend, though, which is that patients are being asked to pay out of pocket for these procedures, which is something that has gone on quietly only for the very wealthy for a long time. But in my practice here in Texas, I’m seeing patients who are working class with diagnosed breast cancer who are visiting with plastic surgeons, offering to do their surgeries now for cash payments, and those payments are $40,000 to $60,000.

Breast reconstruction has really come a long way since it was covered under the WHCRA, so it’s important to recognize that insurance coverage has helped the status and the level of breast reconstruction in our country.

Breast reconstruction using your own tissue used to involve removing a patient’s muscle. So patients had a surgery that removed a large portion of their core muscle in order to rebuild a breast, which really just left the patients with another medical problem that was lifelong, so a woman facing breast cancer who needed a breast reconstruction using her own tissue was left weaker, and with a lifelong hernia or other difficulty with strength, unable to do the things that most patients and people want to do with their daily lives.

So we, as surgeons, developed a better technique. We developed a surgery that involves not taking any muscle, just taking the skin and fat to create the breast and the blood vessels that are needed. We leave the muscles — the core muscles, the six-pack muscles — functioning and strong so that after breast construction, a patient who has faced breast cancer can move along with their life and thrive. They can go for a run, they can pick up their children, they can be active, they can do whatever job they need to do. They’re not weakened long-term.

That difference in terms of the actual experience of the patient is reflected exactly in the coding. The coding for the more difficult surgery, the more delicate surgery, allowed for us to distinguish that surgery from the more barbaric surgery.

I think it’s important to say that the older surgery was very easy on the surgeon to perform, but very hard on the patient to recover from. And the new surgeries, these DIEP flap surgeries and other perforator flap surgeries, put the work appropriately on the surgeon. So, they’re very hard to perform. They’re stressful, they require a lot of time and intense monitoring, but they’re much easier on the patient, which is appropriate.

So with this coding change and equating those two very different types of surgery — and not only equating them, but then shifting the reimbursement down to the lesser surgery — you can see how number one, patients don’t have access to the healthier option and they’re going to live lifetimes affected by an inferior surgery. And number two, surgeons aren’t reimbursed appropriately, so we’re going to see not only that women can’t find access to those surgeries, but also that we lose that knowledge base that it’s taken a decade or more for surgeons to develop and to perform that delicate surgery.

It’s really important to recognize that we already have health disparities in breast cancer, and that that runs the spectrum, right? We know that women of color are more likely to be diagnosed with advanced breast cancers of more aggressive subtypes at an earlier age with more recurrences. We know that women of color are more likely to die from breast cancer.

We also know that women of color with this change are going to be disproportionately affected. Women with more advanced breast cancer more often need radiation, and when radiation is included as part of breast cancer treatment, the reconstructive options are limited. Implants are not a good option in the setting of radiation, the complication rate is very high.

The reason we have natural-tissue reconstruction is certainly because it’s a choice, and we know that patients deserve to have choice in terms of the type of reconstruction. But we also know that clinically, natural-tissue reconstruction is really superior in the setting of radiation, and that’s taking out of the equation all the other wonderful things about natural-tissue reconstruction.

So for women of color who are already diagnosed with more advanced breast cancers or going to need radiation, if we lose this option, then they are going to be faced with the choice of having a reconstruction that is not right for them, that is more dangerous, that has a higher rate of complication. They may even not have reconstruction at all because they don’t have access to the natural tissue- reconstruction.

So women who have radiated breasts or radiated chest walls might have an implant, which has a high complication rate, or they might have a muscle-removing surgery, which is just barbaric and really sets us back to pre-1980.

I think that physicians have to engage with their insurance companies and their societies.

I started a nonprofit, the Community Breast Reconstruction Alliance, and we’ve worked really hard with government agencies and lawmakers and societies to raise awareness around this issue. Most importantly, we’ve worked with patients so that patients are informed. I think that surgeons and other doctors who treat breast cancer can get involved with the Community Breast Reconstruction Alliance and raise their voice. That’s very helpful.

Importantly, I think that doctors need to reach out to their insurance companies and say that this just isn’t right.

This is such an important issue at this moment in time. Healthcare isn’t what it once was when I was growing up and even when I was training. We lived in a different environment of healthcare and really now we’re seeing a lot of challenges to the equitable practice of healthcare in the United States. This is just another example of how difficult it’s becoming for doctors to offer the right care for their patients.

It’s really a moment in time where we need to hold the line and say ‘Enough is enough.’ This isn’t just about money. Insurance companies can’t dictate the surgeries and treatments that we offer as a physician. My goal is to take care of my patients, and this is an example of how convoluted that process has become in the last 10 years.

As I said, I think we need to hold the line and insist on great patient care — insist on having access for our patients to the best care that we know is good for them long-term.