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!
CMS Hearing To Reconsider DIEP flap Breast Reconstruction S Code
Changes to a specialized insurance code (known as the “S-Code”) are limiting patient access to highly specialized, “natural” breast reconstruction procedures that use the patient’s own tissue instead of implants. Access to DIEP flap surgery, which is the gold standard muscle-preserving procedure, is being hit particularly hard.
Breast implants and are the most commonly used method of breast reconstruction in the US. However, implants can leak or rupture, have high re-operation rates, and can also be associated with Breast Implant Illness (BII), and malignancies such as Anaplastic large-cell lymphoma (ALCL). Ensuring patients have access to breast implant alternatives under insurance is therefore a priority.
WHAT IS THE “S-CODE”?
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 codes allow US plastic surgeons to bill insurance plans for these more complex procedures that require additional training and expertise.
CMS CODING CHANGES
In 2019, CMS combined all microsurgical breast reconstruction procedures together under one code (CPT 19364). In January 2021, following a request from a major insurance company, CMS made the further decision to eliminate the S-codes. These codes will sunset on December 31, 2024. After that date, surgeons performing DIEP flap surgery will only be able to bill insurance plans using the same code as the older, less sophisticated free TRAM flap.
Despite the S-codes still being in effect until December 31, 2024, a handful of insurance plans have already declared their intent to stop covering DIEP flap surgery under the S-code. Some have temporarily back-tracked due to patient backlash, but insurance companies will likely continue down this path once the codes sunset. As a result, it is possible that only the most wealthy of American patients will have access to these modern surgeries after December 2024.
A MASSIVE WIN FOR PATIENT ADVOCACY
Thankfully, following immense public pressure and feedback, CMS recently announced they are holding a hearing on June 1, 2023 to reconsider these breast reconstruction coding changes. You can see the full CMS meeting agenda for the June 1, 2023 hearing here.
CMS wants to hear about the obstacles patients are facing in getting access to DIEP flap surgery. Please sign up to attend the hearing and share your comments – use this link to register (enter agenda item #1).
You can also email your thoughts and any experiences you’re comfortable in sharing ahead of the meeting to HCPCS@cms.hhs.gov. Please speak from the heart and explain why you feel it is crucial to preserve full patient access through insurance, and the right to choose any reconstructive option after a mastectomy, including advanced muscle-preserving procedures like the DIEP flap. Please feel free to personalize and edit this letter, or borrow snippets as you see fit.
Every voice helps. Please take this opportunity to have your voice heard!
