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The Use Of Unlisted Billing Codes For Microsurgical Breast Reconstruction And Implications For Code Consolidation
Colby J. Hyland, MD1, Alan Z. Yang, MSc
2, Matthew Carty, MD
1, Jessica Erdmann-Sager, MD
1, Andrea L. Pusic, MD
1, Justin M. Broyles, MD MPH
1;
1Mass General Brigham, Harvard Medical School, Boston, MA, USA,
2Harvard Medical School, Boston, MA, USA
Purpose: The Centers for Medicare and Medicaid Services recently decided to maintain S-codes for autologous reconstruction, calling into question coding practices and how coding consolidation could impact future patients.
Methods: The Massachusetts All-Payer Claims Database was used to identify patients who underwent microsurgical breast reconstruction following mastectomy (2016-2020). Multivariable logistic regression tested whether S2068 claims were associated with insurance and median household income by patient ZIP code. Student’s
t-test was used to compare total charges and payments for codes between insurance types.
Results: There were 272 claims for S2068 and 209 claims for CPT 19364. S2068 claims were associated with age<45 (OR:1.89, 95%CI:1.11-3.20, p=0.019), affluent ZIP codes (OR:1.11, 95%CI:1.03-1.19, p=0.004), and private insurance (OR:16.13, 95%CI:7.81-33.33, p<0.001). Total payments were significantly higher from private than from public insurers for both S2068 ($20992 vs. $8245, p<0.001) and CPT 19364 ($9856 vs. $3294, p < 0.001). Providers in all but two counties used S-codes more frequently than CPT 19364 among privately-insured patients.
Conclusions: Coding practices for microsurgical breast reconstruction lack uniformity. Payments for S2068 versus CPT 19364 differed greatly. Younger, privately-insured, and patients from affluent towns were more likely to receive S-codes. Given higher reimbursement rates and S-code use among privately-insured patients, providers in most counties could expect a 30-40% reduction in total payments for privately-insured patients with code consolidation, which could significantly impact access to care.
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