DIEP Flap Breast Reconstruction Coding

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Question:

I did a breast reconstruction with DIEP free flap, exploration and preparation of the right internal mammary artery and vein for microvascular anastomosis, insertion of an indwelling pain catheter to the abdominal wall, insertion of the Doppler probe to flap artery and vein, and partial resection third rib.

The codes I bill are:
19499 – DIEP flap
35761 – Exploration of artery and vein
11981 – Insertion of indwelling pain catheter to the abdominal wall
37799 – Insertion of the Doppler probe
21600 – Partial resection of the third rib

I’m having a hard time getting paid on all these codes. Can you please help?


Answer:

Sure! Let’s look at the actual CPT descriptions of the codes you are billing:

Your Codes       CPT Description
19499                Unlisted procedure, breast
35761                Exploration (not followed by surgical repair), with or without lysis of artery; other vessels
11981                Insertion, non-biodegradable drug delivery implant
37799                Unlisted procedure, vascular surgery
21600                Excision of rib, partial

In reality, there is a single CPT code for breast reconstruction with a free flap – 19364 (Breast reconstruction with free flap). This code includes the following activities, per ASPS and CPT guidelines:

  • Elevation and transfer of flap
  • Closure of donor site
  • Breast contouring
  • Microvascular transfer (identification, exploration, transfer and anastomosis of vessels)
  • Rib resection

Furthermore, conventional coding guidelines consider intra-operative Doppler and post-operative pain management (eg, placement of a pain catheter) inclusive to the primary procedure of 19364. So the bottom line is that one CPT code describes the DIEP flap breast reconstruction – 19364.