Important News for Breast Reconstruction Patients: CMS DIEP Flap S-Code Decision
The Centers for Medicare & Medicaid Services (CMS) has made a decision about how modern, muscle-preserving breast reconstruction procedures like the DIEP flap are coded for billing purposes. This decision comes after receiving valuable feedback from patients and healthcare providers on the plan to sunset the “S-codes”, emphasizing the increasing importance of the patient’s voice and patient advocacy in healthcare policy decision-making.
The CMS Decision
CMS originally planned to sunset the S codes used by surgeons and insurance companies for reimbursement of complex breast reconstruction procedures like the DIEP flap. However, they reversed course after listening to feedback from patients and healthcare providers like your doctors. “We will be maintaining HCPCS Level II codes S2066, S2067, and S2068 and will not sunset their availability on December 31, 2024.”
Why Were The Breast Reconstruction Codes Scheduled To Sunset?
CMS wanted to simplify how they label different breast reconstruction surgeries. They believed that using specific codes could help both doctors and insurance companies communicate better about these procedures. However, they now understand that the changes could have caused confusion and would limited affordable patient access to modern breast reconstruction options through insurance.
What Stays the Same?
CMS has decided not to make any S-code changes for now. The current codes that describe breast reconstruction procedures will remain in place for the time-being. This means that your access and insurance coverage for these surgeries should not be affected for the foreseeable future.
What Does This Mean for You?
If you’re planning to have a breast reconstruction procedure, this news means that you won’t have to worry about any sudden changes in how your insurance covers the surgery. The codes that your surgeon(s) use to bill insurance companies will also stay the same.
What Can You Do?
Keep using your voices and communicating with your doctors and healthcare providers about your breast reconstruction plans. If you have questions or concerns about insurance coverage, please be sure to ask them for guidance. They are here to help you understand your options and the potential impact of any changes in the insurance landscape that could impact your care or access to it. Patient advocacy works!
4 Tips For Managing Financial Stress During Breast Cancer
Common side effects of cancer treatment include nausea, hair loss, pain, and fatigue. However, the potential impact of the financial costs of care on the patient and their family—also referred to as financial toxicity—is a greatly under-appreciated, hidden “side-effect” that sets-in at the worst possible time. According to a recent study, nearly 80% of women experience financial stress during breast cancer treatment.
Fortunately, there are many resources dedicated to making cancer treatment more affordable. Here are some helpful tips for coping and managing financial stress during and after a cancer diagnosis:
1. Don’t be afraid to ask for help.
Say “yes” if friends or family offer to help. They can help you with paperwork, analyzing and paying bills, checking out your insurance, and gathering information about payment plans. If possible, bring someone who is helping you with your financial responsibilities, and have them ask lots of questions. Also, remember, family and friends often want to help, but often don’t know exactly how. Consider delegating anything you feel comfortable delegating, even in part, to take some of the weight off your shoulders.
2. Contact organizations for help with cancer-related costs.
There are many organizations that can help with expenses related to medical treatment, food, dental care, everyday living, legal resources, and more. Reach out to your HR department at work, or a hospital financial adviser for insight on how to get the most out of your insurance, including help with deductibles and co-pays.
3. Reach out to non-profit organizations.
Many national and local breast cancer organizations provide financial assistance to patients (and their families) to help decrease financial stress during breast cancer treatment. Ask your health care team if they have any recommendations. Other patients you meet can also be a very valuable resource for information on organizations they have found helpful themselves.
4. Tell your doctor immediately if you are concerned about the financial costs.
It’s important to be aware of upfront and out-of-pocket costs when discussing treatment options with your medical team. Your team may be a able to tailor your treatment in a more cost-effective way without negatively impacting your care. Knowing more about the costs that lie ahead is also very important so you can plan and budget accordingly.
Helpful Resources During and After Breast Cancer Treatment
There are many reputable organizations that can help you and your family after a breast cancer diagnosis. To access them, download the Breast Advocate App free here. Click on “Knowledge Center” and then “Resources”. There you will find links to organizations that can provide assistance in many ways, including financial:
Please also let us know of any organizations that you have found helpful. We are constantly adding reputable resources and would love to hear your recommendations!
Patient Access To DIEP Flap Breast Reconstruction In Jeopardy
Patient access to DIEP flap surgery and other modern breast reconstruction procedures is under threat in the US because of changes in insurance coding by the Centers for Medicare & Medicaid Services (CMS).
Breast Reconstruction Options
Women diagnosed with breast cancer, or a genetic mutation that predisposes them to the disease, will need to consider mastectomy as one of their countless treatment decisions. Several options are available for those who choose to have breast reconstruction. These include (i) autologous “flap” reconstruction (using the patient’s own tissue), or (ii) implant-based reconstruction (insertion of a breast implant).
Microsurgical (or “free flap”) reconstruction refers to tissue transplanted from another part of the patient’s own body. The skin and fat below the belly button feels very similar to breast tissue. It is therefore the preferred option to replace the tissue removed by a mastectomy.
The traditional technique that uses the lower abdominal tissue is known as the TRAM (transverse rectus abdominis myocutaneous) flap. This sacrifices the patient’s abdominal muscle as part of the procedure. Since it removes all or part of a woman’s core abdominal (rectus abdominis) muscles, TRAM flap surgery can be associated with long hospitalizations, prolonged recovery, decreased abdominal strength, and a higher risk of abdominal complications such as hernia formation.
As breast reconstruction techniques have evolved, the DIEP (deep inferior epigastric perforator) flap revolutionized reconstruction by providing a natural, warm, soft breast without permanently damaging the abdominal muscles. Since the DIEP flap preserves abdominal muscle, it is associated with shorter hospital stays, faster recovery, and a lower risk of complications compared to the TRAM flap. For these reasons, the DIEP flap is considered today’s gold standard in breast reconstruction.
Coding Changes – What Happened?
The DIEP flap and other advanced, modern microsurgical breast reconstruction procedures (like the GAP flap, stacked flaps) currently have unique billing codes in the US, known as “S-codes”. These specialized billing codes allow US plastic surgeons to bill insurance plans for these more complex procedures that require additional training and expertise.
In 2019, CMS combined all microsurgical breast reconstruction procedures together under one code (CPT 19364). In January 2021, CMS made the further decision to eliminate the S-codes. Sunsetting of these codes is scheduled for December 31, 2024. After that date, surgeons performing a DIEP flap reconstruction will only be able to bill insurance plans using the same code as the older, less spohisticated free TRAM flap technique.
Despite the S-codes still being in effect until December 31, 2024, some insurance plans are already declaring their intent to stop covering DIEP flap surgery under the S-code. 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. In fact, this situation is already playing out. Very soon, it is possible that only the most wealthy of American patients will have access to these modern surgeries. If we don’t act now, this situation will become the new status quo in the US.
What This Means for Patient Access
According to Breast Advocate founder and PRMA Plastic Surgery President, Dr. Chrysopoulo, “CMS coding changes alone do not make surgeries defunct. What we have here is a patient access issue.”
The Women’s Health Cancer Rights Act (WHCRA) of 1998, states that insurance coverage must be provided for your breast reconstruction, symmetry procedures of the remaining breast, and treatment of complications like lymphedema, if you are receiving benefits in connection with a mastectomy and choose to have breast reconstruction.
Unfortunately, the current language in the WHCRA is dated and does not go far enough in protecting patient access to modern reconstruction techniques like the DIEP flap.
What Breast Advocate founder, Dr. Chrysopoulo, Has To Say
“Ultimately, what good are breast reconstruction rights if patients don’t have access to modern surgical techniques?”, says Dr. Chrysopoulo. “Now is the time for patients and surgeons to come together and push for WHCRA to be updated. This is the only way to ensure patients continue to have access to all their post-mastectomy reconstructive options long-term, regardless of what happens on the coding front, which is extremely political.”
How Can You Help?
We strongly urge patients to use their voices! Please contact your state’s Senator or Representative immediately: request this coding issue is remedied, and WHCRA is updated to ensure insurance companies provide full patient access to all modern breast reconstruction options, regardless of the billing codes used now and in the future.
For your Senator’s and Representative’s details please click here.
For a sample letter click here.
FDA Reports Rare Cancers in Scar Capsule Around Breast Implants
According to a recent report from the U.S. Food and Drug Administration (FDA), squamous cell carcinoma (SCC) and various lymphomas may develop in the capsule that forms around breast implants. The lymphomas are not the same as the breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) that prompted previous FDA announcements. The FDA learned about the newly associated cancer during a post-market review of breast implants.
It is very important to know that these cancers are extremely rare. Less than 20 cases of SCC and fewer than 30 cases of lymphoma were found in the capsule around a breast implant.
“After an initial extensive review, we currently believe that the risk [for squamous cell carcinoma] and other lymphomas occurring in the tissue around breast implants is rare,” said Binita Ashar, MD, director of the Office of Surgical and Infection Control Devices in the FDA’s Center for Devices and Radiological Health. “However, in this case, and when safety risks with medical devices are identified, we wanted to provide clear and understandable information to the public as quickly as possible.”
The Type of Implant Probably Doesn’t Matter
The type of implant appears to be irrelevant – all types of implants (smooth, textured, saline, and silicone) have been linked to SCC and lymphomas in the scar capsule around the implants. In some cases, women were diagnosed years after the placement of their implants. Some signs and symptoms include swelling, pain, lumps, or skin changes.
If you are considering breast implants or currently have them, the FDA recommends the following:
- Ensure you are fully educated about the risks and benefits of breast implants.
- Be aware that cases of SCC and various lymphomas in the capsule around the breast implant have been reported, but they are rare.
- You should monitor your breasts and implants by regular self-exam and contact your plastic surgeon about any changes.
- File a report through MedWatch if you experience any problems.
What Doctors Should Know
If you are a healthcare professional caring for patients with breast implants, the FDA recommends you:
- Be aware that cases of SCC and lymphomas in the capsule around the breast implant have been reported.
- When examining breast implant specimens for diagnostic evaluation, characterize all findings and potential diagnoses.
- Report cases of SCC, lymphomas, and any other cancers in the capsule around the breast implant to the FDA.
The FDA said their consumer and healthcare recommendations don’t affect the previously provided suggestions on BIA-ALCL. They are continuously assessing the post-market safety of approved breast implants and will communicate any findings as soon as new information is available.
If you would like to learn more about ALL your breast reconstruction options, download the Breast Advocate App free today!
Breast Cancer: When to Get a Second Opinion?
Considering a second opinion? It is important to know you can get a second opinion at any time during your treatment. This can be very helpful to ensure you are as comfortable as possible with your treatment plan. If you are considering getting another opinion however, we recommend you do so at the beginning of your cancer care if possible to allow for a change in treatment if needed.
“Anytime a patient is given a diagnosis that is maybe not the most common, or maybe has some intricacies or nuances, then it’s probably a good idea to meet with multiple physicians who can give opinions on treatment plans for that unique diagnosis,” says Dr. Jessica Burns, a breast cancer surgeon for ProMedica, and Dr. Christopher Lutman, a gynecologic oncologist with Mercy Health in a recent article.
At first, it might feel like you are doubting your doctor’s judgment, however, it’s a fairly common request that doctors are used to hearing.
When to Consider a Second Opinion
- After biopsy results: The biopsy involves taking a small sample of the breast mass or area of concern to examine it for malignant (cancerous) cells. Any discrepancy by the pathologist who interprets the results could make a difference in your diagnosis and the treatment approach the is recommended. When considering a second pathology opinion, check the service is “in-network” and covered by your insurance plan.
- Before surgery: Getting a second opinion from another breast surgeon or plastic surgeon can be helpful if you are unsure about the type of breast cancer surgery or reconstruction you should have. The decision between having a lumpectomy or mastectomy, and equally choosing aesthetic flat closure or breast reconstruction, can be extremely personal. There is often no “right” or “wrong”; only what is best for you. Given the variety of breast reconstruction options available, it is a good idea to consult with more than one plastic surgeon if you are considering reconstruction, especially if you are considering of the more complex procedures like the DIEP flap. Just as some breast surgeons don’t offer oncoplastic surgery at the time as a lumpectomy, some plastic surgeons don’t offer microsurgical flap options.
- When planning treatment after surgery: Treatment options after surgery can include chemotherapy, radiation therapy, hormonal therapy, and targeted therapies. The best treatment for you will depend on the details of your diagnosis, the pathology results from surgery, and your individual needs. Sometimes, the recommendations can be very clear-cut based on well-established guidelines. Occasionally, the situation isn’t so clear and a second opinion from another specialist can be very helpful to help you navigate your options.
- During treatment: If the treatment plan isn’t working, you have treatment-related issues your doctor can’t resolve, or you aren’t comfortable with an aspect of your care, it’s likely worth seeking a second opinion.
- After treatment: Even if you’ve already finished treatment, you may still benefit from an alternative perspective when it comes to a survivorship care plan. Unfortunately, it’s after treatment that many patients feel the most lost. If you don’t feel you have the support or guidance you need from your medical team, it may be beneficial to get a second opinion.
Helpful Resources
If you are already confident with your original physician’s/team’s treatment recommendations, that’s great! Other resources you can explore that can provide additional support include reputable online support groups and the Breast Advocate App.
How Does Your Age Impact Your Breast Reconstruction Choices?
It is a misconception that patients can be “too old” for breast reconstruction. Age is only one of many factors surgeons take into account when determining if a patient is a good candidate for surgery. In addition, some older women are under the impression their only option is implants. However, this is not necessarily the case either.
What is DIEP flap breast reconstruction?
Ideally, ALL breast reconstruction options should be available to older women. This includes the most advanced breast reconstruction procedure available today—the DIEP flap. The DIEP flap uses the patient’s own lower abdominal skin and fat to recreate a warm, soft, “natural” breast after a mastectomy. The DIEP preserves all the abdominal muscles allowing patients to experience less pain, recover quicker, and maintain their core strength long-term. Sparing the abdominal muscle also lowers the risk of abdominal complications.
Age alone does not disqualify a patient from being a DIEP flap candidate. In fact, a recent study took a closer look at how older women undergoing DIEP flap reconstruction compared to younger women having the procedure. Here’s what the study uncovered…
Is the DIEP flap a good option for older women?
After following 83 DIEP flap breast reconstruction patients over the age of 65, the study found these older patients had similar success and complication rates to younger patients. Likewise, older woman expressed a high satisfaction rate after choosing the surgery.
The authors of the study concluded that the DIEP flap is a safe option for older women and the procedure should be encouraged for breast reconstruction in women over 65 years of age.
“This is something I see reflected in my own practice,” shares Breast Advocate® founder Dr. Minas Chrysopoulo. “Age is only one of many factors I take into consideration when determining which breast reconstruction procedure is best for a patient. Personal motivation as well as physiological age are more important criteria for patient selection than chronologic age alone. Overall health status is far more important. Many of my patients over 65 are very good DIEP flap candidates.”
Ultimately, the best way to determine if you are a candidate for the DIEP flap is to be evaluated by a surgeon experienced in performing these procedures.
Does Chemotherapy Increase the Risk of Breast Reconstruction Complications?
For anyone interested in having breast reconstruction, trying to decide the best time to have it can be yet one more overwhelming decision. Generally speaking, you can have reconstruction at the same time as the mastectomy (this is called immediate reconstruction), or any time later (known as delayed reconstruction). Several factors can influence the timing of breast reconstruction surgery. These can include personal choice, access to a plastic surgeon, and other breast cancer treatments like chemotherapy and radiation.
Does Chemotherapy Impact Breast Reconstruction Planning?
Numerous studies show a higher risk of breast reconstruction complications in patients who have radiation, but the impact of chemotherapy on reconstruction is not as clear.
Chemotherapy can be given before surgery (known as neoadjuvant) or after surgery (adjuvant). A recent study published in JAMA Surgery followed 1881 women undergoing breast reconstruction (both implant-based and with autologous flaps). The study evaluated complication rates and patient reported outcomes. Chemotherapy (either before or after surgery) did not increase the risk for complications in patients undergoing breast reconstruction, regardless of technique. Likewise, there was no link between chemotherapy and any adverse patient satisfaction scores or poor psychosocial well-being.
When is the Best Time to Schedule Your Breast Reconstruction?
This information can help empower women needing to make informed decisions regarding breast reconstruction timing in the setting of chemotherapy.
Patients should engage in shared decision-making conversations with their healthcare team to determine the best time for their breast reconstruction based on their individual needs and clinical situation.
For patients looking for help navigating breast reconstruction timing questions with their surgeons, the Breast Advocate® app can help! After taking users individual situation and preferences into account, the treatment Wizard provides evidence-based recommendations to review and discuss with your healthcare team. Download the free app today HERE.
Breast Cancer Patients Needing Radiation Therapy Face Higher Risk of Implant Reconstruction Complications Requiring Additional Surgery
Implant-based breast reconstruction is the most commonly performed method of reconstruction in the United States today. While the procedure can be performed in one surgery (known as ‘direct to implant’), most women have a 2-stage approach beginning with tissue expanders. These are replaced with a permanent implant a few months later at a second surgery (stage 2).
Implants are a good option for many women but may not be the best choice for some patients. In particular, patients needing radiation therapy as part of their breast cancer treatment should know that radiation increases the risk of complications after reconstruction with implants. Potential complications include infection, capsular contracture (breast hardening), asymmetry, seroma, pain, implant rupture, and implant exposure. In many cases, additional surgery is required to address the complication.
Implants often need to be removed
A recent study published in The Breast Journal found that 44% of women with locally advanced breast cancer who had implant reconstruction needed unplanned implant removal when radiation therapy was part of their treatment plan.
The study followed 52 patients who had mastectomy, implant-based breast reconstruction, and radiation therapy from 2010 to 2017. 44% of the patients in the study had stage III disease, 77% were estrogen receptor positive, and 75% were HER2 positive.
Patients were followed for just over 3 years following surgery and treatment. The average time between treatment and implant removal was only 5 months. In this study, implant removal was required before starting radiation in 17% of the patients, and after radiation was completed in 27% of the patients.
Reasons for implant removal before radiation began were infection (44%), wound breakdown (33%), hematoma (11%), and concern about planned radiation (11%). Reasons for implant removal after radiation included significant breast asymmetry (57%), infection (21%), a deflated expander (14%), and seroma (7%). Some women had bilateral mastectomy and reconstruction – most of the complications in these cases occurred in the breast that underwent radiation therapy.
This study is yet another example of why it is important for patients to be fully informed of the potential risks associated with surgery they choose. Fully-informed patients also tend to have more realistic expectations, which in turn can also improve recovery and the overall satisfaction with the final outcome.
You have other options!
Fortunately, implants are not the only reconstructive option and most women are candidates for alternative procedures. These include other types of breast reconstruction using the patient’s own tissue (known as ‘flaps’), and aesthetic flat closure (going flat).
“Despite the relatively high rate of implant removal reported in this study, salvage reconstruction is feasible,” the study authors noted. “Of the 23 patients who experienced unplanned implant removal, 78% were able to undergo salvage reconstruction with only 5 patients pursuing no further reconstruction at the time of last follow-up.”
If you are facing a similar situation and would like to learn more about your options, the Breast Advocate app can help – download it today!
The Importance of Knowing All Your Breast Cancer Surgery Options
Breast Advocate founder Dr. Minas Chrysopoulo recently joined the C-Sessions podcast for a discussion on breast cancer surgery, breast reconstruction, the potential adverse effects, and the importance of knowing all your surgical options throughout any stage of the breast cancer treatment journey.
Randall Broad graciously hosted the conversation which included Christine, a breast cancer survivor. Christine openly shared her experience of multiple lumpectomies, an eventual mastectomy, and then multiple attempts to reconstruct her breast with implants. A major contributing factor to Christine’s frustration has been the lack of access to all the information she felt she needed to make fully-informed surgical decisions from the get-go following her breast cancer diagnosis.
Christine’s experience unfortunately isn’t unique. When it comes to breast reconstruction in particular, 1 in 3 women feel they don’t have enough say in their treatment decision-making. The Breast Advocate® app was created to address this problem. Breast Advocate provides all the information patients need to make fully-educated decisions about which procedure is best for them after a breast cancer diagnosis. Download it free here.
Listen to the C-Sessions podcast here.
1 in 3 Women Don’t Have Enough Say in Their Breast Reconstruction Decision-Making
Patient’s relationships with their healthcare team can play a major role when it comes to planning medical procedures. In the setting of breast cancer surgeons can greatly influence surgical decision-making. This is particularly the case when it comes to breast reconstruction.
In the largest ever behavioral study focused on breast surgeons and breast cancer patients, results suggest surgeons play a bigger role in breast reconstruction planning than many patients would prefer. The study, published in the British Journal of Surgery, surveyed 53 surgeons, 101 breast cancer nurses, and 689 patients diagnosed with breast cancer.
According to the study, “approximately one in every three women (32%) stated their surgeon had more input than they did, when deciding which type of breast reconstruction to undergo.” Additionally, 16% of women felt they had zero input in the choice of reconstructive procedure they had. We find it very concerning that so many women in this study feel they played little to no role in deciding which type of breast reconstruction was best for them.
The Importance of Shared Decision-Making
This study is yet another example of why shared decision-making is so important, and why we created the Breast Advocate app!
We believe patients should be fully informed of all their breast reconstruction options, as well as the option of aesthetic flat closure (no reconstruction with a nicely-contoured, truly flat result). It is only once all the options are fully discussed, that patients can take part in a shared-decision-making conversation with their surgical team.
Shared decision-making occurs when the health care professional and patient work together to make a treatment decision that is best for the patient. The best decision takes into account evidence-based information about treatment options, the physician’s knowledge and experience, and the patient’s preferences and values. Multiple studies show this collaborative approach improves patient outcomes and satisfaction.
Co-created by leading breast cancer specialists and patient advocates, our free breast cancer surgery app provides evidence-based information and customized surgical recommendations, personalized for each individual user based on diagnosis and personal preferences. Regardless of an individual’s situation, users will have all the information and tools they need to take a more active role in decisions about their treatment.
