September 1, 2023
Advocacy Win for Patients: S-Codes Saved for Breast Reconstruction
The Centers for Medicare and Medicaid Services (CMS) has decided to cancel its plans to remove the medical billing S-codes for breast reconstructive surgery – which enable doctors to be reimbursed for DIEP flap operations. The DIEP is seen as the gold standard for breast reconstruction surgery and can give patients a better quality of life post-op as it is a minimally invasive surgery. The initial decision to eliminate the billing codes for this surgery had led to many insurers denying its coverage or reimbursing it at a lower rate. Many health systems advocated against the removal of the codes and, after a “substantial number of responses” the Agency has decided to keep them. Keep reading to learn more about this recent victory.
The Payer Plan to Remove Access
The initial plan to remove the S-codes was driven by the Blue Cross Blue Shield Association. In 2021, the group asked CMS to discontinue the three S-codes, arguing that they were no longer needed. CMS initially decided that the codes would expire at the end of 2024; however, the decision was starting to hinder access to DIEP flap surgery for breast cancer patients. At least two major insurance companies told doctors they would no longer reimburse the surgery at the same rate as under the higher-paying S-codes.
Why the S-Code is Important
The S-codes provide higher reimbursement for more complex procedures like the DIEP flap, in which skin, fat and blood vessels are taken from a woman’s abdomen to create a new breast. Other breast reconstruction alternatives, such as breast implants, generally need to be replaced every 10 years and operations like the TRAM flap take muscle from the abdomen to reconstruct the breast — causing a longer recovery. Because of the surgery’s complexity and required surgical expertise, the DIEP flap surgery is more expensive. Without the adequate reimbursement from the S-codes, many practices would have not been able to perform the procedure and patients would have lost further access. If patients go outside of their insurance network to pay out-of-pocket for the operation, it can them more than $50,000. This would have created a sizeable inequity in our health care system and limited the procedure to only those with significant financial means.