Dr Fragen in the operating room

Immediate Breast Reconstruction and CMS


OK, first off this part of my practice is over and I’ve moved on. But let me relay a story of how CMS (that’s Medicare for the uninitiated) works.
I was asked by one of my local _breast surgeons_ if I would see a patient for immediate breast reconstruction with implants. The patient was to undergo bilateral mastectomies. No problem. I see the patient. Surgery scheduled and goes fine.
I submit my claim forms to CMS and I only get paid for the consult. They say the surgery (immediate reconstruction with implants) is only billable as an add-on to a procedure done by me. This is absurd. I didn’t do the mastectomies. It seems that CMS can write their own rules along the way. My coder followed all the proper rules according to the CPT Code books.
It’s now over 6 months later and it looks like I’m going to have to write off the $400 that Medicare is usually willing to pay for this procedure. Yep, you read that correctly. No offense to all those women with breast cancer needing and wanting this combination of procedures but I can tell you now that at this fee schedule and with this _ease of reimbursement_ I surprised that anyone is willing to do immediate breast reconstruction. This clearly has not been worth my time and energy, even to get paid.
Side note: If you think the solution to healthcare is to let the government run it; I wish you luck in getting **any** doctors to care for you.