DIEP Flap Breast Reconstruction
1936421600wRVU: 7.08 — Partial rib/costal cartilage resection for internal mammary vessel access (7.08 wRVU, 90-day global) — separately reportable when rib excision is performed to expose recipient vessels
Breast defect following mastectomy for [breast cancer / prophylactic mastectomy]
Same
Deep inferior epigastric perforator (DIEP) flap breast reconstruction, [right / left / bilateral]
[Attending name], MD
[Resident/Fellow/PA name]
General endotracheal
Patient with history of [breast cancer / BRCA mutation] status post mastectomy desiring autologous breast reconstruction. Adequate abdominal donor tissue available. [Prior radiation to chest wall.] CTA perforator mapping performed preoperatively. Dominant perforators identified at [zone / location]. Risks including flap loss, fat necrosis, abdominal hernia, asymmetry, and prolonged operative time discussed. Consent obtained.
Perforator vessels identified as planned on preoperative CTA. Dominant perforators: [right / bilateral] periumbilical. Pedicle length [X] cm. Venous drainage via [single / double] accompanying veins. Recipient vessels: internal mammary artery and vein at [second / third] intercostal space.
The patient was positioned supine and prepped from chest to mid-thighs. Two surgical teams proceeded simultaneously.
FLAP HARVEST: An elliptical abdominal skin island was marked centrally including the umbilicus. The skin island was incised and the flap raised by dissecting through the abdominal fat to the anterior rectus fascia. The dominant perforator(s) were identified entering the fat and dissected retrograde through the rectus muscle, carefully separating muscle fibers without dividing them (intramuscular dissection). The pedicle was traced to its origin from the deep inferior epigastric artery and vein. Pedicle length [X] cm achieved. The flap was divided and passed off the table. Anterior rectus fascia closed with [running 0 PDS / mesh]. Drain placed. Abdomen closed in layers. Umbilicoplasty performed.
RECIPIENT SITE PREPARATION: The [second / third] intercostal space was accessed [by excision of the intercostal cartilage / using a rib-sparing technique dissecting through the intercostal space]. The internal mammary artery and vein were exposed and isolated under loupe magnification.
MICROVASCULAR ANASTOMOSIS: Under the operating microscope, end-to-end anastomosis was performed between the DIEP pedicle artery and internal mammary artery with [9-0 / 8-0] nylon interrupted sutures. End-to-end venous anastomosis was performed [with a [3-mm] microvascular coupler device / with [9-0] nylon interrupted sutures]. [A second venous anastomosis was performed between the [deep inferior epigastric vein / superficial inferior epigastric vein] and the [second internal mammary vein / thoracodorsal vein] to optimize venous outflow.] Clamps released with robust flap perfusion and venous outflow confirmed. Handheld Doppler signal [audible].
The flap was inset and contoured to recreate the breast mound. Excess skin de-epithelialized. Flap dermis inset with 3-0 Vicryl. Skin closed with 3-0 Monocryl. Patient tolerated the procedure well.
None
None
[200-400] mL
[Two] JP drains: [one] at flap, [one] at abdominal donor site
Patient taken to PACU/ICU in stable condition. Hourly flap checks initiated.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Breast defect following mastectomy for [breast cancer / prophylactic mastectomy]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Deep inferior epigastric perforator (DIEP) flap breast reconstruction, [right / left / bilateral]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with history of [breast cancer / BRCA mutation], status post mastectomy desiring autologous breast reconstruction. Adequate abdominal donor tissue available. [Prior chest wall radiation.] Preoperative CTA perforator mapping identified dominant perforators at [zone / location]. Risks including flap loss, fat necrosis, abdominal hernia, and prolonged operative time were discussed. Informed consent obtained.
FINDINGS: Perforators identified as planned on preoperative CTA. Pedicle length *** cm. Venous drainage via [single / double] accompanying veins. Recipient vessels: internal mammary artery and vein at [second / third] intercostal space.
DESCRIPTION OF PROCEDURE:
Patient positioned supine. Prepped chest to mid-thighs. Two teams proceeded simultaneously. FLAP HARVEST: Elliptical abdominal skin island marked centrally including umbilicus. Flap raised through abdominal fat to anterior rectus fascia. Dominant perforator(s) dissected retrograde through rectus muscle without dividing muscle fibers. Pedicle traced to origin from deep inferior epigastric artery and vein. Pedicle length *** cm achieved. Flap divided. Anterior rectus fascia closed with running 0 PDS. Abdomen closed in layers. Umbilicoplasty performed. RECIPIENT SITE: Second/third intercostal cartilage excised [rib-sparing technique used]. Internal mammary artery and vein isolated under loupe magnification. MICROVASCULAR ANASTOMOSIS: Under operating microscope, end-to-end arterial anastomosis with 9-0 nylon interrupted sutures. End-to-end venous anastomosis with 3-mm coupler device [second venous anastomosis performed]. Clamps released. Robust perfusion and venous outflow confirmed. Doppler signal audible. Flap inset and contoured to recreate breast mound. Excess skin de-epithelialized. Dermis inset with 3-0 Vicryl. Skin closed with 3-0 Monocryl. Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: None
COMPLICATIONS: None
DRAINS: Two JP drains (one at flap, one at abdominal donor site)
DISPOSITION: Patient taken to PACU in stable condition. Hourly flap checks initiated.
Signed: .ME, .MYDEGREE
.TODAYVariants
TRAM flap (pedicled)
CPT 19367 (single-pedicled, 26.13 wRVU) or 19369 (bipedicled, 30.53 wRVU). Pedicled on the superior epigastric artery (continuation of internal mammary). The entire ipsilateral rectus abdominis muscle is mobilized and tunneled subcutaneously to the chest — not a muscle segment. Document muscle preservation attempts, degree of muscle sacrifice, and fascial closure technique. Higher hernia/bulge risk than DIEP due to full muscle harvest.
Bilateral DIEP
Two separate flaps for bilateral reconstruction. Document bilateral pedicle harvest, recipient vessel preparation, and anastomosis for each side. Billing: Medicare modifier -50 on a single line (1 unit); some commercial payers require -RT/-LT on separate lines. Document bilateral operative planning in the note.
Delayed reconstruction
Secondary procedure after prior mastectomy and radiation. Document scar tissue management at recipient site and vessel quality.
Charting Tips
- Document preoperative CTA perforator mapping findings including perforator location (zone), number, and caliber
- State pedicle artery and vein size at takedown
- Microvascular anastomosis: document number of arterial and venous anastomoses, technique (interrupted suture vs. coupler), suture size, and ischemia time — the 19364 descriptor includes one artery and two veins; document accordingly
- Flap perfusion assessment: Doppler signal, color, capillary refill at completion
- Abdominal fascial closure technique (primary suture vs. mesh reinforcement) — document explicitly given hernia/bulge risk
- Postoperative flap monitoring protocol must be established (frequency, clinical parameters, rescue plan)
- If rib/costal cartilage resection performed for IM vessel access, document as a distinct step to support CPT 21600 billing
Billing Tips
- CPT 19364 (free flap breast reconstruction, 41.52 wRVU, 90-day global) covers DIEP, SIEA, and all free tissue transfer for breast reconstruction for Medicare claims. For most commercial payers (BCBS, UHC, Aetna, Cigna) and many Medicaid programs, use HCPCS S2068 (DIEP flap) — commercial payers reimburse S2068 at 50-70% more than 19364. CMS confirmed in August 2023 that S2068 (along with S2066 for GAP flap and S2067 for SIEA flap) will be maintained indefinitely. Verify payer-specific preference before submitting.
- TRAM flap alternatives: 19367 (single-pedicled TRAM, 26.13 wRVU), 19368 (single-pedicled TRAM with supercharge anastomosis, 33.05 wRVU), 19369 (bipedicled TRAM, 30.53 wRVU). These are standalone primary codes describing entirely different techniques — they are NOT add-ons to 19364. Use 19364 only for free flaps requiring microvascular anastomosis.
- Global period is 90 days. All routine post-op care is bundled. Flap monitoring visits and standard wound care are not separately billable.
- Two-surgeon billing: when a co-surgeon performs the vessel anastomosis, both surgeons may bill 19364 with modifier -62 (co-surgery). Document distinct roles in the operative note. Note: many commercial payers deny modifier -62 on 19364/S2068 when both surgeons share the same specialty — verify payer policy and document the distinct contribution of each surgeon.
- Bilateral reconstruction: for Medicare, append modifier -50 to a single line item (1 unit); reimbursement is 150% of the unilateral fee schedule amount. Some commercial payers accept -RT/-LT on two separate lines — verify payer policy.
- Recipient site vessel preparation (internal mammary artery and vein dissection) is bundled into 19364. However, CPT 21600 (partial rib resection, 7.08 wRVU, 90-day global) can be separately reported when partial rib or costal cartilage excision is performed specifically to access the internal mammary vessels. Document the rib excision as a distinct step if performed.
- Document flap harvest dimensions, recipient vessels used, ischemia time, number of arterial and venous anastomoses, and method of anastomosis (end-to-end vs end-to-side) for both clinical accuracy and coding defensibility.
General coding reference. Verify with your institution’s billing department before submitting claims.