Commercial Insurance Rates and Coding for Lymphedema Procedures: The Current State of Confusion and Need for Consensus

Abstract

Background: Surgical treatment of lymphedema has outpaced coding paradigms. In the setting of ambiguity regarding coding for physiologic procedures [lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT)], we hypothesized that there would be variation in commercial reimbursement based on coding pattern. Methods: The authors performed a cross-sectional analysis of 2021 nationwide hospital pricing data for 21 CPT codes encompassing excisional (direct excision, liposuction), physiologic (LVB, VLNT), and ancillary (lymphangiography) procedures. Within-hospital ratios (WHRs) and across-hospital ratios (AHRs) for adjusted commercial rates per CPT code quantified price variation. Mixed effects linear regression modeled associations of commercial rate with public payer (Medicare and Medicaid), self-pay, and chargemaster rates. Results: A total of 270,254 commercial rates, including 95,774 rates for physiologic procedures, were extracted from 2863 hospitals. Lymphangiography codes varied most in commercial price (WHR, 1.76 to 3.89; AHR, 8.12 to 44.38). For physiologic codes, WHRs ranged from 1.01 (VLNT; free omental flap) to 3.03 (LVB; unlisted lymphatic procedure), and AHRs ranged from 5.23 (LVB; lymphatic channel incision) to 10.36 (LVB; unlisted lymphatic procedure). Median adjusted commercial rates for excisional procedures ($3635.84) were higher than for physiologic procedures ($2560.40; P < 0.001). Commercial rate positively correlated with Medicare rate for all physiologic codes combined, although regression coefficients varied by code. Conclusions: Commercial payer–negotiated rates for physiologic procedures were highly variable both within and across hospitals, reflective of variation in CPT codes. Physiologic procedures may be undervalued relative to excisional procedures. Consistent coding nomenclature should be developed for physiologic and ancillary procedures.

Discussion: Comparing Trends in Medicare Reimbursement and Inflation within Plastic Surgery Subspecialties

“…11,12 Moreover, some procedures such as vascularized lymph node transfer, prophylactic lymphovenous bypass, and vascularized regenerative peripheral nerve interfaces, which lack their own appropriate CPT codes, may benefit from having specific codes to more appropriately capture RVUs and align reimbursement with the true amount of physician work and expenses involved in providing these procedures. 13 Aside from influencing coding, plastic surgeons can directly advocate for changes to how the CMS is instructed to determine physician reimbursement. Two targets for reform have been the MACRA and the Social Security Act.…”

“…11,12 Moreover, some procedures such as vascularized lymph node transfer, prophylactic lymphovenous bypass, and vascularized regenerative peripheral nerve interfaces, which lack their own appropriate CPT codes, may benefit from having specific codes to more appropriately capture RVUs and align reimbursement with the true amount of physician work and expenses involved in providing these procedures. 13…”

Free Flap Reconstruction in the Era of Commercial Price Transparency: What Are We Paying For?

“…This database has been previously used as the substrate of scientific analysis in peer-reviewed studies published within various academic journals. 7,[10][11][12][13][14] As of October of 2022, Turquoise Health data encompassed 60,755,118 negotiated rates from 65% (n = 4195) of US hospitals. 15 CPT codes for free flap operations (Table 1) were used to query the Turquoise Health database to extract all disclosed rates for the corresponding procedures.…”

United States insurance coverage of immediate lymphatic reconstruction

“…reimbursement for LVB and VLNT based on the CPT codes used. 35 Additionally, they reveal that reimbursement for physiologic procedures, such as LVB and VLNT, is comparatively lower than excisional, despite their greater technical complexity.…”