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

Dialogue pertaining to the CPT coding system for lymphatic procedures is long overdue. We therefore commend the authors for their recent publication¹ and for bringing this matter to light, as there continues to be a lack of consensus around CPT coding of lymphatic operations. Recently, a greater clinical consensus has been developing in terms of procedural algorithms for the surgical management of lymphedema. History has shown that the standardization of best practices as demonstrated by the establishment of Centers of Excellence, along with consensus on CPT coding, will promote the passage of medical policy. Although we agree with the authors that CPT coding is an important step toward policy change, we also strongly believe that concurrent efforts toward standardizing the delivery of care are of equal importance. For example, recent progress toward clinical consensus has driven medical policy change to provide coverage for the surgical treatment for lymphedema in Massachusetts.²

In the process of standardizing the CPT coding framework for lymphatic operations, it is also critical that consistent nomenclature be developed for these procedures. We have previously observed that how we document our procedures can significantly impact whether or not they are reimbursed.² We proposed a standardized framework of referring to lymphatic operations as “lymphatic reconstruction.” Lymphatic operations performed for prevention would be termed “immediate lymphatic reconstruction” and those performed in a delayed manner (ie, after the development of lymphedema) would be termed, “delayed lymphatic reconstruction.” The latter category would include debulking, lymphovenous bypass, and lymph node/vessel transplantation. Attention to procedural nomenclature is of equal importance to CPT coding when approaching third-party payers for policy change.

Overall, the evaluation of CPT coding and valuation should arise from consideration of intraoperative time, surgeon skill set and training, and the intensity of the procedure. These factors compete directly with the concept of relative value unit budget neutrality. Use of existing CPT codes may appear to be the most feasible and efficient option for arriving at a consensus; however, existing codes do not entirely encompass the actual value of a procedure. We agree with the authors that previous cost-effectiveness studies strongly argue in favor of appropriate reimbursement for lymphatic procedures.^3–5 Sekigami et al.⁵ and Johnson et al.³ further strengthen this argument, recognizing variation in payment for lymphatic procedures through sensitivity analyses, and demonstrating that the value of physiologic procedures for lymphedema are cost-effective even in the setting of higher surgical payments. Continued undervaluation and inadequate reimbursement introduce the risk of deterring future surgeons from entering this burgeoning field, thereby resulting in recession of the field before it can grow. As the authors note, we also believe that the creation of new CPT codes is paramount for the field to flourish and achieve its potential. The introduction of new CPT codes is necessary, as lymphatic reconstruction generates unique benefits for patients that are different from those represented by existing CPT codes. Furthermore, establishment of new CPT codes is most likely to support appropriate valuation of lymphatic procedures, thereby representing the time and skill commitment of lymphatic surgeons.

A CPT Coding Working Group was initiated at the 2023 Annual Meeting of the American Society for Reconstructive Microsurgery. Although the authors believe that finding consensus on the use of existing CPT codes is important until new codes are established, we believe the primary aim must be the establishment of new codes. Only in the case in which this goal is not able to be accomplished should application of existing codes for lymphatic procedures be considered, if strict agreement is reached by our colleagues as to which current codes are used for each procedure. Overall, the development of a new CPT coding framework, formalization of best practices, and standardization of care are of equal gravity and are necessary for further advancing the passage of medical policy for lymphatic reconstruction. The importance of timely and prompt attention to lymphatic reconstruction reimbursement cannot be overstated, as the future of its widespread appropriate adoption depends heavily on whether or not plastic surgeons can feasibly adopt these techniques into their practice. Delays in addressing reimbursement harms not only the surgeon but most importantly the patients who depend on these clinically proven operations to treat lymphedema and also prevent lymphedema from occurring. At worst, further lack of appropriate reimbursement threatens to irreversibly eviscerate the very momentum of lymphatic surgery adoption among plastic surgeons that presently is surviving in a select few specialty centers. We thank the authors for their timely and important work.