On August 21, a substantial stride in securing microsurgical breast reconstruction access was realized with the Centers for Medicare & Medicaid Services announcing the HCPCS Level II codes S2066, S2067, and S2068 (pertaining to DIEP, GAP, and SIEA flaps) would not be discontinued. The decision to maintain these codes, initially set to phase out on December 31, 2024, was the outcome of a CMS public meeting convened in response to concerns raised by various stakeholders.
On February 16, 2022, the Centers for Medicare & Medicaid Services (CMS) announced plans to discontinue the three microsurgical breast reconstruction HCPCS Level II Codes: S2066, S2067 and S2068 effective December 31, 2024. Upon issuance of this announcement some insurers acted immediately to issue policy changes stating the codes S2066-2068 would no longer be reimbursable with an effective date of July 1, 2022 more than a year in advance of CMS’s stated date of termination. Instead, the historical CPT Code 19364 would become the omnibus code under which all flap procedures would fall, with the S-codes no longer reimbursable under certain policies.
By July 2022, the outcry from the industry along with notable media outlets spotlighting the impact on patients’ access to care, insurers such as UHC temporarily halted the coverage/coding changes. Several interested parties took action including the American Society of Plastic Surgeons (ASPS) who provided comment on June 1, 2023 requesting reconsideration of the decision to delete the S-Codes.
The ASPS responded that the “categorical reductions in private payer valuation of microsurgical breast reconstruction [that] are triggering disturbing losses in access to this type of care” further stating “the private insurance industry is treating the sunset of the S-codes as an opportunity to reclassify microsurgical breast reconstruction as a lower-level procedure. There should be no difference between payors’ internal value for the procedure variations covered under S2066-2068 and their value for CPT 19364 with the transition in coding. The same perforator flap techniques are covered under both types of codes. The clinical resources and level of surgical skill required do not change simply because the procedure is described with a different code.”
In reversing its earlier decision, CMS added that it is now unambiguous that multiple codes now describe the DIEP, GAP and SIEA procedures. While CMS acknowledged that CPT code 19364 describes a DIEP, it is equally as clear that 19364 describes many different flap procedures and CMS based its reversal, in part, on concerns that payors were seeking to reclassify microsurgical breast reconstruction as a lower-level procedure. Payors will need to consider the complexity of the services and skill level of the provider in resolving payment negotiations and disputes relating to these surgeries, whether billed as a 19364 or as originally billed with a HCPCS S2068.
CHRMS remains committed to monitoring regulatory changes that impact out-of-network provider reimbursements. Should you have any questions, please contact our office.