Billing Codes Affect Healthcare Access - It's A Head Scratcher

by  Find-A-Code™
May 1st, 2023

It is understandable that someone new to medical billing codes would understand them as little more than alphanumeric representations of medical services designed to keep track of payments. That they are. But they are so much more. In fact, billing codes have become so integral to how healthcare services are provided that they can actually affect patient access.

A case in point are the revised codes dealing with breast reconstruction surgery following cancer-related mastectomy. Revisions to how deep inferior epigastric perforator (DIEP) flap surgery gets coded will allow insurance companies to pay less for the procedure.

It's a head scratcher. The procedure itself hasn't changed. It is the same procedure today as it was a year ago. How can it be that refining medical billing codes relating to breast replacement surgeries changes how much DIEP costs? Nonetheless, it does.

A Very Good Option

According to an NPR report from WHYY, the most common reconstruction surgery following mastectomy involves silicone breast implants. Breast implantation surgery is pretty straightforward and comparatively inexpensive. But implants need to be modified or replaced every 10-15 years, on average.

Some women do not respond well to implant surgery. There are other options, including DIEP. DIEP relies on harvesting skin, fat, and blood vessels from the lower belly to rebuild breasts. It is a highly technical procedure that can only be performed by plastic surgeons with specialized training. It's also very expensive compared to implantation surgery.

DIEP is a particularly good option for women who try all the other procedures unsuccessfully. Despite being complex and costly, the main benefit DIEP brings to the table is its lifetime effectiveness. Most women who undergo the surgery never have to worry about it again. Reconstruction lasts a lifetime.

New Codes Change Everything

With the introduction of the new medical billing codes for DIEP, it is virtually guaranteed that insurance carriers will either reduce provider reimbursements or drop coverage altogether. Where does that leave plastic surgeons and patients? Between a rock and a hard place.

The NPR story profiled a woman who underwent a double mastectomy as a result of cancer. She now says she feels disfigured. She also doesn't know how she would be able to live this way permanently, if forced to do so. She has tried all the other options to no avail, and she is now considering DIEP. But will she be able to afford it?

Plastic surgeons and patient advocates are concerned that most women who could benefit from the surgery will not be able to cover the out-of-pocket expenses. It is possible that some plastic surgeons will take what they can get from insurance carriers and bill patients for the balance. But if reimbursements are low enough, plastic surgeons may simply stop offering the procedure altogether.

It's Not Supposed to Be This Way

Medical billing codes were originally established as a way to streamline billing and increase efficiency. As far as we know, they were never intended as a tool to help insurance companies manipulate reimbursement rates. Yet that is exactly what has happened in this case. It's not supposed to be this way.

The unfortunate truth is that medical billing codes have grown and morphed into something that goes beyond their original design. Our healthcare system now revolves around billing instead of patients and their care.

Things don't look like they will change at any point in the near future. So for now, the reality is that billing codes can affect healthcare access. Change one or two codes and it's possible that an entire segment of the population will be denied viable treatments that they otherwise would have had access to.