Breast forms not created equal

Tuesday, March 31, 2009

HOUSTON--The American Association of Breast Care Professionals (AABCP) in February formed a committee to evaluate existing codes for post-mastectomy products.

Despite many advances in technology, Medicare still only recognizes eight codes, one code for each type of product, said Rhonda Turner, AABCP’s executive director.

“There are different materials and different processes out there (that didn’t exist five years ago),” she said. “The existing codes and reimbursements don’t reflect that.”

The five-member committee is comprised of manufacturer representatives familiar with design and manufacturing, and insurance industry representatives that understand coding and reimbursement. Their job: To evaluate the technologies and features offered on different manufacturers’ products to determine how well each item fits within current code language.

By analyzing coding, the AABCP will be in a better position to make recommendations to CMS on new codes, said Turner. The purpose is not to try and make more money, but “more appropriate reimbursement” could result in higher payments, she said.

“Right now, every size, type, shape, attachment and procedure is all paid for at one reimbursement rate under one code,” Turner said. “But a breast form is not a breast form is not a breast form. What would be appropriate to one woman would not be appropriate to another.”

For example, very lightweight breast form for a woman with specific clinical issues or one that attaches directly to the chest wall, are more expensive to make - and provide - than more basic breast forms.

“If you receive a basic form, it is going to be the least expensive, but some of these are more costly so providers just eat the additional cost,” said Turner.