Mastectomy + Reconstruction: reimbursement Q

[Dr JPH]

Gen Surg & Plastics trained surgeon does the mastectomy and immediate reconstruction.

Does he/she get paid for both?

Someone told me today that the surgeon wouldnt get paid for both portions of the procedure.

Just curious.

Thanks.

---

Members don't see this ad.

 

[Leforte]

Depends on what the actual surgons did. If the both scrubbed for all portions, they can both bill, but they add a modifier for a second surgeon. this usually reimburses 20% above the reimbursement for one surgeon. So if collection is ~$800 for the mastectomy (and I have no idea what it is), they would get $960 together, or $480 a piece.

Keep in mind that reimbursement works something like this:
100% collection for the 1st procedure (not what you billed, but what the reimbursement is)
50% collection for the second procedure
25% collection for the third procedure
25% collection for the fourth procedure
Nothing for anything billed above that

So le't say you were my attending last week for this procedure for an advanced laryngeal CA:
Direct laryngoscopy
Esophagoscopy
Bronchoscopy
Laryngectomy
Left neck dissection
Right neck dissection
Cricophayngeal myotomy
Pectoralis flap
Split thickness skin graft

You would bill for all procedures, but only get reimbursed for 4 of them, at the percentages listed above. The other 5 procedures you will not get paid for.

For our advanced free flaps, we use two head and neck surgeons. One does the resection, one the reconstruction. They bill separately and there is no co-surgeon for the procedures. Otherwise, for a 14+ hour case, one could only bill for 4 procedures (out of probably 12+).

So to get back to your questions, they may have billed together, or separately for the resection and reconstruction.

Wish I could apply this to the rest of the world - can you imaging going out for dinner, paying 100% for appetizer, 50% for the main course, 25% each for a two drinks, the rest of the drinks and dessert is free! Or any car repairs! How about grocery shoppng?

This is of the reasons many private practice docs won't do the complex cases - hard to justify when a few small outpatient cases quickly reimburse more than extensive cases that do not pay and you are rounding on for the next 7 days.

Leforte

PS - oops just realized that you question is for one surgeon - so the first portion of the reply applies. the rest is just FYI then.

 

[maxheadroom]

Not many plastic surgeons will do both a mastectomy and the recon. I've seen Ollie post on this subject recently -- he might be able to shed some light on the issue.

I know that when we do skin cancers on the face that we only get paid for either the resection on the closure, but not both. This makes lots of plastic surgeons happy to have a Derm/MOHS guy take off a cancer and then the plastician reconstructs without having to wait on FS.

OK, Ollie, enlighten us!!

 

[droliver]

I do the mastecomy/recon thing not infrequently. As outlined you get screwed on a sliding scale after the highest RVU CPT code.

My coding for that would include CPT codes for:
1) Mastectomy (simple) 19180
2) Immeadiate insertion tissue expander - 19357
3) & 4) Placement of Alloderm 100 cm2+ (there'd be 2 codes for the size commonly used) - 15330 & 15331
5) Intercostal Nerve Block - 64421 (yes you can actually get paid for this and it takes about 20 seconds when you're staring at the chest wall)

For malignant skin cancers, simple closure is included with the resection CPT code. For intermediate or complex closures, local flaps, or grafts you can submit a 2nd closure code. There's talk from CMS that they will include all types of closure other then flaps & grafts in the CPT for the resection in the future as they do with benign lesions.

 

[maxheadroom]

So Ollie, have you had any problems with the local general surgeons for doing your own mastectomies? In my locale it would be something of a turf war -- pretty much the only guys doing them here are surg onc and the one "breast" trained surgeon.

Which expanders are you using? And what do you use as a final implant? I'm more and more impressed by the Inamed 410, although I have limited experience . . . at our place the indication for an implant is that the patient refused DIEP/SIEA. ;-)

 

[droliver]

Most of the mastetcomies I do are prophylactic on patients who come to have a plastic surgeon do it (b/c they think it will look prettier I guess🙂 ). I prefer to do them myself because I think I can do it in a way to make the reconstruction easier and I usually do nipple sparing procedures.

I use mostly high-profile Inamed silicone gels. The Inamed 410 & Mentor CPG are still not available except to a handful of investigators (and even then they only get openings in the study enrollment in wierd intervals). I expect the 410 to be approved later in the year by FDA if I'm reading the tea leaves right. I will begin using the 410 (which I had the chance to use during my breast fellowship) as soon as I get my hands on them.

For expander reconstructions, I've gone to releasing the inferior pectoralis & using Alloderm as a sling in nearly 100%. Total muscular coverage is very painful for the patient and nearly 100% of the time makes the implant stay too high on the chest wall. I probably use the Inamed 400 cc MV (moderate height) expander on 9 out of ten patients except for the largest or smallest patients.

I like to do TRAM's but only in fairly thin patients as they get minimal fat necrosis IMO. I do not like bilateral TRAMS (either free or pedicled) as I think it compromises the abdominal wall too much.

SIEP, DIEP, & GAP free flaps do not get done outside of teaching programs and mastering those is wasted time for 99% of those in practice. While elegant, these reconstructions have been HMO'd out of existence and cannot be done economically without being heavily subsudized or if you have a unique niche like Bob Allen in Charleston,SC and have a practice of people paying you (reportedly) $25-30K cash to do their perforator flap in out-of-network fee for service relationships.

 

[I am Hans]

My plastic surgeons allow the surgical oncologists, breast surgeons or general surgeons to do the mastectomy...skin sparing or whatever and then they step in for the reconstruction.

It was explained to me that the plastic surgeon and the oncologic surgeon have different goals...the plastic surgeon would like the flaps thicker for a better cosmetic result while the onco surgeon is trying to get all the cancerous and possible cancerous tissue out, so makes them (the flaps) very thin.

Obviously Dr. Oliver has a different experience... regional and practice based differences I would imagine.

 

[droliver]

I don't want to give the impression that I do a majority of the mastectomies for which I do reconstructions on. However, I have no problem doing mastectomies and axillary disections for cancer treatment when people drift into me for that reason.

It a little bit of a generalization, but I don't think most surgeons really understand the true anatomy of the breast and it's anatomic boundries. It's rare that I see some surgeons not uneccesarily violate the inframammary fold, extend the disection latereral or superior to the true anatomic breast, or mistake subcutaneous fat for breast tissue. Taking the pectoral fasica (a common surgical manuever) is also absolutely not neccesary unless the tumor is adjacent.

Some really thin people will have thin flaps by neccessity, but most of the time it's a misunderstanding of anatomy by the surgeon. Each of these little missteps in the mastectomy compromises the quality of the reconstruction.