Wiki Bilateral Breast Reconstruction with acellular dermal tissue matrix

[mamarchant]

We are a plastic surgery practice whose surgeon often performs bilateral placement of tissue expanders in immediate breast reconstruction. He will also place acellular dermal tissue matrices at the time of the expansion (CPT code 15777, an add-on code). We typically bill 19357-50 and 15777-50. As the 15777 code is an add-on code, the bilateral procedures have NOT been reduced accordingly to multiple procedure guidelines when billed with the 19357 (even though 19357 second breast is reduced). One insurance is now trying to retract 1/2 payment on the second 15777 code. Should this second 15777 be reduced according to multiple procedure guidelines even though it is an add-on code?

 

[thomas7331]

Under the Medicare physician fee schedule, 15777 has a multiple procedure indicator of '0' which means it is not subject to reduction. Theoretically, if your payer is basing reimbursement on the Medicare fee schedule, they should not be reducing this code. However, non-Medicare payers do sometimes come up with their own rules for multiple procedure reductions, so it's hard to say if they're making a mistake or just following a different set of rules. If you have a contract with this insurance, there should be something in there in writing that gives you the details of how they will pay you.