Essentially Women Mastectomy Guide
Entering the Post-Mastectomy Business Post-mastectomy providers are located across the United States. Providers could be independent boutiques who only do post-mastectomy services and billing, lingerie boutiques, salons, orthotic and prosthetic (O&P) providers, located within another Home Medical Equipment (HME) business or hospital, or a gift shop located in a hospital. Are you looking to open your own post-mastectomy boutique or add post-mastectomy to your current HME business or O&P practice? This guide will help.
Table of Contents Market ..........................................................3 Facility Accreditation......................................3 Mastectomy Fitters.........................................4 Continuing Education Requirements..............4 Location ........................................................4 Additional Products to Carry .........................5 Business Considerations ................................6 Billing and Reimbursement ...........................7 Codes ............................................................8 Resources ......................................................9
Essentially Women Mastectomy Guide
Market The post-mastectomy market isn’t going away any time soon. According to the American Cancer Society, 1 in 8 women in the United States will be diagnosed with breast cancer sometime in her life.1 There are also more than 3.8 million breast cancer survivors in the United States. The Women’s Health and Cancer Rights Act (WHCRA)2 provides protections to patients who choose to have breast reconstruction in connection with a mastectomy. If a woman is receiving benefits in connection to a mastectomy, coverage must be provided for prostheses and treatment of physical complications of all states of the mastectomy, including lymphedema.
Within your community, look to the physicians who treat breast cancer patients. This will most commonly be found in a cancer treatment facility. Within those practices you will have medical oncologists, breast surgeons, nurse navigators, and support groups play a vital role in helping women during their breast cancer journey. Ask about current options for post-surgical products and services to uncover the needs are and gaps in services for your community.
Facility Accreditation To gain insurance and Medicare billing privileges, your business will need to be accredited. There are eight CMS-approved accreditation organizations for the durable medical equipment, prosthetic, orthotic, and supplies (DMEPOS) category. The purpose of accreditation is to ensure the businesses providing patient care have proven their business practices and are compliant with the standard of care required to bill Medicare. Most third-party payers and state Medicaid programs also require facility accreditation. While there are eight CMS-approved organizations, two provide accreditation for businesses offering only mastectomy services: The American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABCOP) and the Board of Certification/Accreditation (BOC). ABCOP Mastectomy Facility Accreditation Guide3 BOC Facility Accreditation Information4 Essentially Women encourages you to contact these organizations and decide based on the organization that best meets your needs regarding the products and services you intend to offer in your business.
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Mastectomy Fitters The American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABCOP) and the Board of Certification/Accreditation (BOC) both offer individual certifications for mastectomy fitters. For members that pursue their accreditation through ABCOP or BOC, they must have a certified mastectomy fitter on staff. Individuals must complete an approved pre-certification educational course. ABCOP candidates must complete 250 hours of mastectomy fitting while working under another certified mastectomy fitter and complete a checklist of competencies prior to sitting for the mastectomy fitter exam. ABCOP: Certified Fitter of Mastectomy (CFm) BOC: Certified Mastectomy Fitter (CMF)
Continuing Education Requirements Certified mastectomy fitters for both ABCOP and BOC must earn a total of 10 continuing education credits every five years. Eight hours of scientific credits and two hours of business credits are required. Contact ABCOP and BOC for the complete requirements for certification renewal.
The Essentially Women Focus Conference offers CEU’s each year for mastectomy fitters. Attending one Focus Conference generally allows a member to earn all their credit requirements.
Location The location of a post-mastectomy business should include at least one private fitting room, retail floor space, a waiting area, and inventory storage space. Please also check with your accreditation company’s minimum floor space requirements.
Essentially Women Mastectomy Guide
Post-mastectomy providers typically have a variety of bra and prosthetic types, styles, and sizes available to try on during fittings. Selling custom breast prostheses does not require inventory space as each product is specially manufactured for each person. If you’re interested in offering custom breast prosthesis, be sure to check out our guide.
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Additional Products to Carry Post-mastectomy providers may choose to carry additional reimbursable and non-reimbursable items to make their clients’ lives easier. • Compression garments, including ready-to-wear knit sleeves for lymphedema management • Skin care specially designed for sensitive skin • Post-mastectomy swimsuits • Camisoles with pockets for prosthetics • Breast Cancer Awareness gifts and items • Recovery clothing or robes featuring drain pouches • Pajamas • Shirts that can help protect surgery incisions, ports, or drain pouches • Wigs* • Head scarves and coverings • Cosmetics • Shoes (fashion or orthopedic) • Pillows (heart shaped, curves for arms, seatbelt pillows) *May need a licensed cosmetologist on staff for cutting and styling a wig
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Business considerations E-Commerce Consider setting up your business website with an e-commerce portion. Many incremental sales items can be purchased online. Some businesses also allow for post-mastectomy items to be purchased online and require that the patient submit the item herself to her insurance company for reimbursement. If this seems appealing, make sure you have a strong return policy in place and communicate it well. Also consider how you could provide excellent customer service online. Many post-mastectomy retailers do not have an e-commerce website as they would prefer to have a more personal connection with their clients.
Resupply There are revenue opportunities on offering resupply. Depending on the prescription, most mastectomy bras are prescribed as a certain number per quarter. You can contact your existing customers. If you’ve provided Medicare reimbursable items to a beneficiary in the last 15 months, it is OK to send customers information or contact them. You cannot actively solicit or prospect new customers. • Telephone solicitation statute (42 U.S.C. § 1395m(a)(17))
Marketing/Branding When planning your post-mastectomy business, think about branding and what you want to be known for in your community, your mission, and your values. Incorporate that strategy into the name of your business. If you are an HME, hospital-based DME, or hospital gift shop, many postmastectomy businesses have separate business names and/or tax IDs for the post-mastectomy segment. For more information on marketing and branding, read the recent VGM Playbook.
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Billing and Reimbursement Reimbursement varies by payer. Some private insurance payers provide coverage for custom breast prosthesis. Always verify patient benefits prior to their appointment. Using a DMEPOS billing software is encouraged. CMS External Breast Prosthesis LCD DME PDAC Off-the-shelf breast prosthesis: • Resupply is allowed every two years • Documented medical need may justify more frequent replacement. For example, patient has gained/lost a lot of weight Mastectomy bra (pocketed): • Some payers will have a defined quantity limit per year, while others may allow quantity based on what is prescribed by the physician • New prescription is needed each year • There is increased wear due to prosthesis held in place by the pocketed bra Custom breast prosthesis: • Resupply allowed every two years unless patient has documented need. For example, gained or lost a lot of weight • Custom breast prosthesis is allowed by many state-Medicaid and third-party payers but is not covered by Medicare. If passed, the Breast Cancer Patient Equity Act legislation would require coverage
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Codes
Code
Medicare description
L8000
Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type
L8030
Breast prosthesis, silicone or equal, without integral adhesive
L8035
Custom breast prosthesis, post mastectomy, molded to patient model
L8001
Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type
L8002
Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type
L8010
Breast prosthesis, mastectomy sleeve
L8015
External breast prosthesis garment, with mastectomy form, post mastectomy
L8020
Breast prosthesis, mastectomy form
L8031
Breast prosthesis, silicone or equal, with integral adhesive
L8032
Nipple prosthesis, prefabricated, reusable, any type, each
L8033
Nipple prosthesis, custom fabricated, reusable, any material, any type, each
L8039
Breast prosthesis, not otherwise specified
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Resources VGM Insurance • Comprehensive liability, including general and professional • Health insurance solutions • Property • Business auto • Workers’ compensation • Umbrella coverage • Directors and officers • Employment practices liability • Cyber liability • Medicare/Medicaid Surety Bonds • Vgminsurance.com | 800-362-3363 American Breast Care training • In-person pre-certification training • Online training for custom breast prosthesis • Online training • ABC University VGM Education • Offers a variety of online education courses including courses in compliance, HIPAA, billing and reimbursement, ABC and BOC recertification CEUs, cyber security • Courses for Essentially Women Members • Vgmeducation.com | 866-227-8171 | vgmeducation@vgm.com Business solutions, mastectomy, and lingerie vendor partners and more can be found on the Essentially Women membership portal.
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800-988-4484 | www.essentiallywomen.com