A recent change to medical billing codes threatens breast reconstruction options for thousands of people. The change pools all tissue-based breast reconstruction surgeries under a single medical billing code, even though there are significant differences in the level of expertise needed to perform different types of surgery.
The coding change, announced during the pandemic by the federal agency the U.S. Centers for Medicare and Medicaid Services, puts at risk the freedom to select DIEP flap, a surgery that allows people to use their own skin and fat to rebuild the breast. DIEP flap is muscle-sparing, and it requires specialized microsurgery to re-attach blood vessels in the flap to the chest. People undergoing DIEP flap tend to recover more quickly than those having other forms of tissue-based surgery. However, it is more expensive than other tissue-based reconstruction, typically costing $50,000 or more. The CMS coding change means surgeons will be compensated at a much lower rate, equivalent to the costs of older forms of tissue reconstruction. Although the change won’t formally take effect until late 2024, some private health insurers have already halted reimbursement for DIEP flat procedures.
In mid-January breast reconstruction surgeon Elisabeth Potter, MD, appeared on CBS News to discuss these issues. But she has been sounding the alarm for months, meeting with professional medical societies and members of Congress to warn of the potential harms to people with breast cancer, hoping to stop the coding change before it went into effect. Now the wheels are in motion, and she is regularly hearing from those seeking DIEP flap reconstruction who cannot find a doctor to perform it or who can only get it by paying cash for the procedure.
This is an issue of equitable access to appropriate, gold standard medical options. It is wrong to restrict a person’s ability to select what may be the most appropriate surgery for their medical condition.
All people with breast cancer have the right to breast reconstruction under the Women’s Health and Cancer Rights Act of 1998. Although a much larger number of people opt for implant-based surgery, DIEP flap remains of significant interest to our breast cancer community. In 2020, more than 23,000 DIEP flap reconstruction surgeries were performed (ASPS). At a price tag of $50,000 or more, the CMS coding change puts DIEP flap out of reach for all but the wealthiest people—if they can find a surgeon to perform it at all. And while most Americans can’t afford to spend that much out-of-pocket, some groups are more likely to be harmed. Extensive past research suggests Black women are more likely to select tissue-based reconstruction than white women (S. Connors, et al; S. Soni, et al). People with more aggressive cancers whose treatment requires radiation are also more likely to choose tissue-based reconstruction, and those people tend to be younger and non-white.
We must move swiftly to right this wrong. Living Beyond Breast Cancer is working with a coalition of doctors, advocates, and community members to apply pressure to CMS and to private insurance companies to re-add the individual billing codes. We are also in touch with members of the U.S. House of Representative and Senate, who have each submitted a letter to CMS requesting they re-add the individual billing codes. Collectively, these efforts seek a immediate solution rather than a legislative one, which we know from our past experience supporting the Lymphedema Treatment Act can take many years. We encourage members of our community who are concerned about this issue to take these steps:
- Enter your zip code in this tool to get the names and contact info for your senator and congressperson
- Contact your congresspeople to share your personal story about why breast reconstruction choices are important to you
- Ask them to pressure CMS to reinstate S2068, the billing code that covers DIEP flap reconstruction, and other codes for specialized breast reconstruction; include your name and zip code so your rep knows who you are
- Contact your private health insurance company and ask them to commit to reimburse DIEP flap reconstruction at an appropriate rate into the future, to ensure people have access to all standard options
Let them know you are aware there is more than one way to have breast cancer—and anyone impacted should have the full range of choices, regardless of their financial circumstances.
We also encourage you to reach out to LBBC by filling out the Share Your Story form to tell us about how this coding changes is now affecting you.