I recently posted some information on one of my instagram stories about the rampant misuse of item numbers by plastic surgeons. Unfortunately I also upset some people along the way, which is a pity because the purpose of this sort of thing is to protect patients (and indeed, to protect our increasingly creaky health systems). As with much of the content I post online, it was prompted by an interaction with a patient.
Ok, so the context here is that as a surgeon who does a fair volume of explant surgery and revision work, two areas in which there really aren't many surgeons who can profess much in the way of expertise, I see many ladies who have had consultations elsewhere (and then come to me I guess because of our experience with complex revision procedures).
What that means is that when I see a patient and then offer them their surgery quotes, they will often have a different quote from a different surgeon for comparison. Now, of course those quotes will vary because every surgeon runs their practice differently and will value their service in whatever way they choose.
Where this becomes problematic is when we send out a quote, and then a patient will come back to us to ask why we haven't used certain item numbers (that were listed on their previous quotes from those other surgeons).
And inevitably, our response is that we have applied ALL item numbers that are appropriate to the case in question. Unfortunately, what we are seeing is that people are receiving quotes elsewhere that are littered with what I consider to be inappropriate item numbers.
So why does this happen? Well, the blame sits (at least in part) with the way the Medical Benefits Scheme in Australia works. The blame also sits with surgeons who are looking to wring every last dollar out of the system that exists. And of course there are additional incentives, like trying to sugar coat the cost of surgery by amplifying rebates to patients (even if that means crossing a few boundaries).
Let's consider a few examples with very common item numbers to illustrate. We're going to consider the failings of the Medicare system to use specific language to prevent misuse of item numbers, and we'll also consider the ways in which some surgeons (in my opinion) misuse these item numbers.
45523/ medically indicated Breast reduction surgery
Ok, this is the item number for breast reduction surgery. The description for that item number reads:
Reduction mammaplasty (bilateral) with surgical repositioning of the nipple:(a) for patients with macromastia who are experiencing pain in the neck or shoulder region; and(b) not with insertion of any prosthesis.
So very clearly, this is intended to facilitate breast reduction surgery for ladies with a big bust, who are experiencing functional difficulties.
What this description does not do is specify any sort of minimum reduction weight to qualify for this item number. That's an issue.
If for example, a lady with a big bust has a pretty standard breast reduction, in my practice that normally entails something between 250g and 800g removed from each breast. Sometimes more. Very rarely less.
The issue then is that because there is no specified lower limit, there are surgeons taking a tiny amount of tissue away (let's say 50g) and doing what is essentially a cosmetic breast lift, but using this item number. And there is nothing, anywhere, to say that that is wrong. But one might argue that it is certainly not in the spirit of what that item number is intended for.
The challenge of course is how to determine what is a "minimum weight of tissue removal" for a breast reduction to qualify as medically necessary, versus the small amount of tissue that many surgeons routinely remove in a cosmetic mastopexy.
So, the question here must be: what is the intention of the surgery?
Clearly the item number for breast reduction was never intended for ladies whose only concern is the cosmetic appearance/shape of the breast.
45558/ medically indicated Mastopexy
This next one is also about surgeons using inappropriate item numbers when a patient is requesting a cosmetic mastopexy.
The specific wording of this item number really matters, because this one doesn't really leave any grey areas so it amazes me that surgeons still try to use this number inappropriately.
The item reads:
Correction of bilateral breast ptosis by mastopexy, if:
(a) at least two‑thirds of the breast tissue, including the nipple, lies inferior to the inframammary fold where the nipple is located at the most dependent, inferior part of the breast contour; and
(b) photographic evidence (including anterior, left lateral and right lateral views), with a marker at the level of the inframammary fold, demonstrating the clinical need for this service, is documented in the patient notes
Applicable only once per lifetime.
Now, the key part of that description relates to the nipple position - the nipple must lie at the most "dependent", inferior part of the breast contour. What that means, in the simplest possible terms, is that unless a patient's nipples are pointing at the floor, this item number DOES NOT APPLY.
And yet, it appears that this number is being freely used for patients who don't meet that criterion, and evidently, there is not policing of this point with review of images to prove its applicability.
45554 & 45553/ medically indicated replacement of Breast Implants
This last one is what I would consider the archetype of inappropriate item numbers use in plastic surgery.
Some background.
Until a few years ago (around 2018 I think) there were item numbers allowed for the revision and replacement of implants without stipulating any specific conditions to allow that. In other words, surgeons who had done purely cosmetic breast augmentation (with no item numbers) were then treating their (typically privately insured patients) years later and replacing their implants with the use of item numbers which then ensured that their hospital, anaesthetic and implant costs were covered by their private insurance...for entirely cosmetic breast implants.
The item number descriptions were updated and all of a sudden, ladies who had previously had some sort of implant revision at close to no cost were being told that now they would have to pay for whatever implant revision surgery they were seeking. Which caused a little consternation in certain places.
But, many surgeons continue to use these item numbers for ladies with purely cosmetic implants because, again, the item number wording is sufficiently imprecise that they can get away with it, even though it is abundantly clear what these numbers are intended for.
I have written quite a bit about this issue over the years on my blog, but it's not going away so here we are again.
The item number description for 45554 reads:
Breast prosthesis, removal and replacement with another prosthesis, following medical complications (for rupture, migration of prosthetic material or symptomatic capsular contracture), including excision of at least half of the fibrous capsule or formation of a new pocket, or both, if:
(a) either:
(i) it is demonstrated by intra-operative photographs post-removal that removal alone would cause unacceptable deformity; or
(ii) the original implant was inserted in the context of breast cancer or developmental abnormality; and
(b) the excised specimen is sent for histopathology and the volume removed is documented in the histopathology report; and
(c) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes
Now, this entire issue hinges on two words in that description: "unacceptable deformity".
As I wrote on my stories when posting about this issue, you show me an "unacceptable deformity" and 99 times out of 100 I'll show you an explant procedure that hasn't been done properly.
To be clear, the intention for the use of 45554 is for ladies who have reconstructive implants (whether for cancer or congenital issues) only. If your implants were placed for cosmetic purposes originally, then any subsequent replacement remains cosmetic. The ONLY medically indicated procedure performed for cosmetic implants that have developed complications is IMPLANT REMOVAL.
"...The ONLY medically indicated procedure with an item number that can be performed for cosmetic implants is implant removal. Anything else remains entirely cosmetic with no applicable item number. "
Look, I understand the motivation to find item numbers and use them. I understand that for a patient who has paid for private insurance over many years without ever really using that insurance, there is a sense that insurance should pick up some of the tab. I understand that for a surgeon, they think they are "helping the patient out" by using item numbers to decrease their out-of-pocket costs to some extent (although I think more often, the surgeon is just trying to incentivise a patient to book surgery by lowering the perceived barriers to surgery).
And ultimately, how some of these numbers are used is completely subjective and will vary from surgeon to surgeon.
But here is the rub: abuse of item numbers offers short term benefit to the surgeon who books the procedure (they get the patient in , they take their surgical fee); but on the other hand it often results in hospitals being substantially under-reimbursed for the procedure, and the anaesthetist often gets screwed as well.
So the surgeon benefits, but everyone else takes a hit. And that leads to the situation we find ourselves in now: hospitals see plastic surgeons as financially unattractive to work with, as do many anaesthetists. And the longer term implications are serious - it is becoming harder for plastic surgeons to get operating lists, which means it is becoming harder for patients to access surgery, and in many ways I think this can be traced back to a long history of plastic surgeons doing cosmetic procedures under inappropriate item numbers.
Our health systems are breaking. This is just a small part of a far larger problem, but if the conversations that I am having with private hospitals are anything to go by, this problem may start to backfire significantly on those surgeons who continue this sort of behaviour.