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.

Figure 1.. Within- and across-hospital variation in GAF-adjusted commercial rate per CPT code for (A) excisional, (B) physiologic, and (C) ancillary procedures.

AHR, across-hospital ratio. LVB, lymphovenous bypass. VLNT, vascularized lymph node transplant. WHR, within-hospital ratio. WHR plots exclude outliers. Note difference in x-axis scale for lymphangiography plots. Red dashed lines separate procedure groups.

Figure 1.. Within- and across-hospital variation in GAF-adjusted commercial rate per CPT code for (A) excisional, (B) physiologic, and (C) ancillary procedures.

AHR, across-hospital ratio. LVB, lymphovenous bypass. VLNT, vascularized lymph node transplant. WHR, within-hospital ratio. WHR plots exclude outliers. Note difference in x-axis scale for lymphangiography plots. Red dashed lines separate procedure groups.

Figure 1.. Within- and across-hospital variation in GAF-adjusted commercial rate per CPT code for (A) excisional, (B) physiologic, and (C) ancillary procedures.

AHR, across-hospital ratio. LVB, lymphovenous bypass. VLNT, vascularized lymph node transplant. WHR, within-hospital ratio. WHR plots exclude outliers. Note difference in x-axis scale for lymphangiography plots. Red dashed lines separate procedure groups.

Figure 2.. Comparative kernel density distributions of GAF-normalized commercial rates for physiologic lymphedema procedures in comparison to (A) excisional lymphedema procedures and (B) breast reconstructive procedures.

LVB, lymphovenous bypass. VLNT, vascularized lymph node transplant. Breast procedures correspond to the following CPT codes: insertion of tissue expander (CPT 19357), breast reconstruction with free flap (19364), and breast reduction (19318).

Figure 2.. Comparative kernel density distributions of GAF-normalized commercial rates for physiologic lymphedema procedures in comparison to (A) excisional lymphedema procedures and (B) breast reconstructive procedures.

LVB, lymphovenous bypass. VLNT, vascularized lymph node transplant. Breast procedures correspond to the following CPT codes: insertion of tissue expander (CPT 19357), breast reconstruction with free flap (19364), and breast reduction (19318).

Figure 3.. Comparison among GAF-adjusted rates per CPT code for excisional and physiologic procedures.

LVB, lymphovenous bypass. VLNT, vascularized lymph node transplant. All rates except for Medicare are normalized based on the Geographic Adjustment Factor (GAF). Red dashed lines separate procedure groups.

Figure 4.. Relationship between commercial and Medicare rates for physiologic procedures.

Graphed values are between 5^th and 95^th percentiles for respective rates. Slope of line approximates coefficient from simple linear regression of commercial rate as a function of Medicare rate: 0.75 (95% CI 0.71 – 0.80, p<0.001).