Billing code change could make popular breast reconstruction surgery harder for cancer survivors to find

ATLANTA - Jamie Cooper of Scottdale, Georgia, has done the math and says she has been to at least 150 medical appointments since she was diagnosed with triple positive breast cancer June 30, 2022.

She was 39, and raising two little ones with her husband Rob.

"So, [they were] 2 and 4 at that time," Cooper says. "And, it's just, like, 'What's going to happen with this?' And, your mind kind of goes to the worst place. It feels like the world is crumbling around you."

Cooper began chemotherapy. In January, she underwent a double mastectomy.

Now at 40, she's wrapping up radiation. Cooper says she will have to wait until she has completed treatment, likely in the summer of 2024, before she can undergo breast reconstruction surgery.

Cooper already knows she wants a natural reconstruction, something known as a DIEP flap procedure.

She says she has been researching the surgery for months.

"To a lot of women, it's a miracle surgery, because it enables you to use your own tissue to reconstruct your loss, and to reconstruct your breasts," Cooper says.

Austin-based breast surgeon Dr. Elisabeth Potter says DIEP flap surgery is a bit like a tummy tuck, at least at first.

"We take the skin and the fat from the lower abdomen," Dr. Potter says. "A lot of women have that, a little extra skin or tissue there. And we find the blood vessels that supply it."

Then, Potter says, they transfer the tissue, fat and blood vessels up to a woman's chest.

"And, I sew those things together so that that tissue is now living on the breast," she says.

Cooper chose a DIEP flap procedure because, unlike an earlier version of the surgery known as a TRAM flap procedure, the DIEP flap does not involve cutting her abdominal muscles.

"So, DIEP flap surgery has a lower complication rate, and a faster recovery, than the older versions of the surgery," Potter says.

"I did a DIEP flap today on a 60-plus-year-old woman," she continues. "She's walking around the room tonight having her dinner. That would never have happened with a TRAM flap."

Cooper will not need implants. Dr. Potter says the procedure is designed to last a lifetime.

But, there's one major roadblock. 

In January, just a day after her mastectomy, Cooper learned a billing code change for insurance could make it harder for her and other women who have undergone mastectomies to get access to the DIEP flap procedure.

Under federal law, insurance companies are required to pay for mastectomies and breast reconstruction for breast cancer patients like Cooper.

However, the law does not specify what type of reconstructive surgery must be covered.

"To find out that this option might not be on the table was devastating," she sys. "It felt like a joke."

As of January 1, 2025, the Centers for Medicare and Medicaid Services, or CMS, says all breast flap reconstruction surgeries will fall under the same medical billing code, which insurance companies use to negotiate reimbursement rates for procedures.

Dr. Potter says the combining of billing codes means that plastic surgeons will be reimbursed at much lower rates for the more complicated DIEP flap procedure, and many may stop performing it.

"I'm seeing surgeons who were excellent at performing these surgeries say, 'I can no longer do it,'" Potter says. "So, what that means is, when people like Jamie go out and try to find the surgery, to find a surgeon to perform it, they're they're not going to find anyone willing or able."

Cooper says the issue is not that DIEP flap surgery is going away.

"It's that less women will have access to it," she says. "Because, when you're talking about, in terms of insurance, that we have the right to reconstruction as survivors, as women with this disease, what good is the right, if we don't have the access to it?"

Cooper's insurance company, UnitedHealthcare, sent a statement to FOX 5:

"There have been no policy changes that impact our coverage or reimbursement for these services. CMS has stated they have delayed the discontinuation of the S codes for this procedure until December 31, 2024."

Dr. Potter says other insurance companies are already refusing to pay surgeons using the old billing code, dramatically reducing reimbursement rates for the procedure.

"And I will say that at any time, United, Blue Cross, Aetna, Humana, they could, according to the rules that exist today, stop paying for DIEP flaps," she says.

Dr. Potter and patient advocates are pushing CMS to reconsider retiring the unique "S" codes that allowed surgeons to bill insurance companies at a higher rate for the more complex procedure.

June 1, 2023, CMS held on online public meeting with breast cancer patients, advocates and physicians to talk about the proposed change.

"So, officially, we won't hear from CMS until August," Dr. Potter says. "And, if they make a change, it wouldn't be in effect until October. So right now, we're continuing to reach out and encourage CMS to make this change, to reinstate those codes. I think we're in a little bit of a waiting pattern to see what they do, but we are still pushing."

Potter says she is encouraged.

"We're seeing positive movement, and I'm thankful that CMS is listening," she says. "But, now we need more action. We need for us to restore these codes and retain them indefinitely."

Jamie Cooper says, whatever happens, she will find a way to get this surgery, even if she and Robert have to fundraise and pull together the money themselves.

Without insurance coverage, a DIEP flap procedure can cost close to $50,000.

"It's one more thing, one more thing that I have to overcome," Jamie Cooper says.