For non-Medicare payers, temporary codes provide the most accurate reporting and reimbursement of these clinically complex procedures.

Unlike other flaps used for breast reconstruction, deep inferior epigastric perforator (DIEP) flaps preserve muscle function at the donor site, improving the patient’s core strength and reducing the risk of hernia after surgery. Conflicting and outdated guidelines mean that coding for DIEP flaps can be a challenge. Here’s what you must know to correctly report these services for proper payment.

19364 vs. S2068: CPT® Is Behind the Curve

The American Medical Association (AMA) states in the December 2011 CPT® Assistant that DIEP flap is properly reported using CPT® 19364 Breast reconstruction with free flap:

Question: Should code 19364, Breast reconstruction with free flap, be used to report the performance of a deep inferior epigastric perforator flap (DIEP) for breast reconstruction?

Answer: Yes. Code 19364, Breast reconstruction with free flap, is the appropriate code to report free flap breast reconstruction, regardless of the specific free flap used. It may be a free transverse rectus abdominis myocutaneous (TRAM), a free DIEP, or a gluteal free flap. Code 19364 is not limited to a particular type of free flap, and it is the code to be used to report any type of free flap breast reconstruction.

Code 19364 includes harvesting of the flap, microvascular transfer (one artery and two veins), closure of the donor site, and transfer to the chest and inset, including the creation of the breast mound. Examples are a free transverse rectus abdominis myocutaneous (TRAM) flap, a free DIEP, or free gluteal flap. Microvascular transfer includes the use of the operating microscope. Code 69990 Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure) is not reported in conjunction with code 19364.

Most knowledgeable clinicians, coders, and (non-Medicare) payers disagree with the above AMA advice (which has not been updated since 2011), and instead call for HCPCS Level II code S2068 Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral to describe DIEP flaps. The reasoning is that DIEP flaps are significantly different — and clinically more involved — than other types of flap included within the definition of 19364.

DIEP Is More Involved than TRAM

“Code 19364 dates from the early ’90s,” explains Steven Pisano, MD, a surgeon and a founding partner of Plastic Reconstructive and Microsurgical Associates (PRMA), in San Antonio, Texas. “That was around the time the TRAM flap was being developed.”

TRAM is a relatively crude procedure, says Pisano, who has participated in over 3,000 breast reconstruction procedures in nearly 20 years of private practice. To reconstruct a breast, surgeons using the TRAM technique harvest skin, fat, and muscle from the abdominal area. Ideally, surgeons prefer to spare the muscle, taking only the skin and subcutaneous fat. But at the time TRAM was developed, there was no effective means to dissect the underlying blood vessels — which had to remain intact to nourish the tissue flap — from the muscle. Everything had to be moved as a “block.” Later, more advanced forms of TRAM (i.e., muscle sparing free TRAM) spared a greater portion of muscle, but all TRAM flaps involve the loss of some abdominal musculature.

The DIEP technique allows the surgeon to keep circulation intact to the skin and subcutaneous tissue of the lower abdomen, while preserving all underlying rectus abdominus muscle. Typically, the DIEP flap is based on one (sometimes more) perforator(s), which passes through the rectus muscle from the DIEP pedicle; the perforator(s) is dissected through the muscle down to the main vascular trunk, which in turn is dissected to the inguinal (groin) region, where the blood supply takes its origin from the femora vessels.

Patients experience less pain after DIEP surgery, versus TRAM, “They also enjoy a faster recovery and maintain their abdominal strength,” Dr. Pisano says. “And because the abdominal muscles are saved, the risk of complications, such as abdominal bulging and hernia, are lower.”

But DIEP flaps are significantly more work than TRAM flaps, Dr. Pisano notes. “It takes considerable more time and effort to identify and dissect the proper vessels through the rectus muscle. If you’re comparing a one-sided free TRAM with a one-sided DIEP, the time difference is approximately 60 to 90 minutes, depending the patient’s anatomy,” he says.

Real World Experience Shows S2068 Works for DIEP

In the “real world” of claims submission and payer preferences, S2068 is favored over 19364 for DIEP flaps, regardless of AMA recommendations.

“Although Medicare does not recognize S codes, including S2068, the rest of the insurance world does,” says Sharon Lacey Supik, practice administrator at PRMA. “Our group of microsurgeons has now collectively performed greater than 7,500 of these free flap procedures, and we do not have a single commercial insurance contract that requests we bill 19364. All commercial carriers, including Medicaid, require us to bill S2068 to accurately describe the work involved with these complex perforator flaps, which are not TRAM flaps.”

Previously (December 2013), based on the information in the above-referenced CPT® Assistant article, AAPC recommended reporting 19364 for DIEP flaps unless your payer specifically requested S2068 (which has been a viable code since 2007). Note: Based on the experience of AAPC members who are billing for DIEP flaps, as well as payer guidelines, AAPC now recommends reporting S2068 for DIEP flaps, unless your payer specifically precludes the use of S codes.

S Codes Do Not Include Bundled Procedures

When reporting DIEP flaps using S2068, National Correct Coding Initiative (NCCI) edits and AMA bundling rules do not apply. In other words, S2068 includes only those related procedures specifically enumerated in the code descriptor (as well as typical intra-service procedures and services). As such, you may separately report related procedures performed during the same operative session.

For example, DIEP flap may be performed without resection of a portion of rib and costochondral cartilage, but only if the recipient vessels (most commonly, the second intercostal perforator vessels from the internal mammary system) are present in the anterior chest wall. If this or other chest wall recipient perforator vessels are not present, are present but of too small a caliber, or have been divided or injured by the mastectomy, then dissection of the internal mammary vessels is required. Exposure of the internal mammary vessels may require partial rib and costochondral cartilage resection; this adds effort, time, and risk (e.g., pneumothorax) to the procedure. You may separately report 21600 Excision of rib, partial when partial rib resection is used to expose the internal mammary vessels.