CommercialBilling CodesHigh impact
11.08.15ad, Reconstructive Breast Surgery and Post-Mastectomy Prostheses
Independence Blue Cross·Plastic Surgery, General Surgery, Oncology·Medical Policy
Effective date
Jan 1, 2026
We identified it
Jun 19, 2026
Summary
Independence Blue Cross has updated policy 11.08.15ad to 11.08.15ae with CPT/HCPCS code revisions effective 01/01/2026. Two HCPCS codes (Q4130, Q4116) have been reformatted to reflect add-on code status with updated descriptions, one NOC code (Q4100) has been terminated and replaced by Q4433, and two C-codes (C5271, C5272) for low-cost skin substitutes have been removed from coverage. Billing teams must update their systems to reflect these code changes to avoid claim denials.
Action Required
By December 15, 2025: Billing team must update billing system to reflect code changes effective 01/01/2026. SPECIFIC ACTIONS: (1) Remove C5271 and C5272 from all claim submission rules and billing templates for skin substitute grafts—these codes are no longer valid and will be denied; (2) Update Q4130 (Strattice) and Q4116 (AlloDerm) code descriptions to reflect add-on code status and ensure they are always billed in addition to primary procedure codes; (3) Replace all references to terminated code Q4100 with Q4433 (361 hct/p skin substitute product, not otherwise specified) and configure Q4433 as an add-on code; (4) Verify all breast reconstruction claim templates and provider encounter forms reference the correct active codes; (5) Brief coding and billing staff on these changes to prevent submission of denied codes after 01/01/2026. Failure to update systems will result in claim denials for skin substitute products and reconstructive breast surgery procedures.