D37. Commercial Insurance Rates and Coding for Lymphedema Procedures: The Current State of Confusion and Need for Consensus

Abstract

PURPOSE: 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: We performed a cross-sectional analysis of 2021 nationwide hospital pricing data for 21 Current Procedural Terminology (CPT) codes encompassing debulking (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: 270,254 commercial rates, including 95,774 rates for physiologic procedures, were extracted from 2,863 hospitals. Lymphangiography codes varied most in commercial price (WHR 1.76 - 3.89, AHR 8.12 - 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 debulking procedures ($3,635.84) were higher than for physiologic procedures ($2,560,40; p<0.001). Commercial rate positively correlated with Medicare rate for all physiologic codes combined, though regression coefficients varied by code. CONCLUSION: 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 debulking procedures. Consistent coding nomenclature should be developed for physiologic and ancillary procedures.