How to code Breast Reconstruction cpt codes
19340 Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
19342 Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion
19361 Breast reconstruction with latissimus dorsi flap; without prosthetic implant
19364 Breast reconstruction with free flap
19366 Breast reconstruction with other technique
19367 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site;
19368 with microvascular anastomosis (supercharging)
19369 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site
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Device Codes for 19342 (Required for OPPS):
C1789 Prosthesis, breast (implantable)
L8600 Implantable breast prosthesis, silicone or equal
Definitions: Breast reconstruction cpt codes involves the creation of a breast mound following a mastectomy using a prosthetic implant, a tissue expander or the patient’s own tissue.
Breast reconstruction cpt codes with insertion of breast prosthesis involves inserting a saline or silicone filled breast prosthesis. Prosthesis insertion performed at the time of the mastectomy is immediate (19340) while insertion performed following the mastectomy is delayed (19342).
Breast reconstruction with a tissue expander (19357) involves inserting an expandable implant. The physician injects saline through a portal under the skin to gradually stretch the surrounding tissue. This procedure is performed at the time of the mastectomy (immediate) or at a later date (delayed).
Breast reconstruction with a latissimus dorsi flap (19361) involves dissecting the muscle from the back, tunneling it through the armpit and suturing it in place.
Breast reconstruction cpt codes with a free flap (19364) involves excising a flap of skin, fat and muscles and reattaching it to the chest with microvascular anastomosis to provide adequate blood supply.
Breast reconstruction with a transverse rectus abdominis myocutaneous (TRAM) flap involves dissecting a skin and fat flap from the lower abdomen, tunneling it up through the chest and suturing it in place. This procedure utilizes a single pedicle flap (19367), a single pedicle flap with microvascular anastomosis (19368) or a double pedicle flap (19369).
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Documentation required for Breast reconstruction CPT codes
History and Physical: A full history and physical should be obtained from the referring physician detailing the signs, symptoms and conditions that deem the breast reconstruction necessary. The physician should be aware of all medications the patient may be taking.
Final Note/Summary: The final note should indicate the procedure(s) performed, and the final pathology findings. Follow up and treatment options should also be documented.
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Indications / Associated Pathology with Breast reconstruction CPT codes
For immediate breast reconstruction, a partial or radical mastectomy performed for a medical reason on the same day.
For delayed breast reconstruction, a partial or radical mastectomy performed for a medical reason several weeks or months ago where the original wound has healed.
Confusion with breast reconstruction CPT codes
Breast reconstruction by tissue expansion, 19357, is performed with either a temporary or permanent tissue expander. When a temporary tissue expander is inserted, the surgeon removes it after the breast mound matches the unaffected breast and replaces it with a permanent prosthesis. This procedure is coded with 11970, Replacement of tissue expander with permanent prosthesis. If the patient or physician determines that it is necessary to remove the tissue expander without inserting a permanent prosthesis, use code 11971, Removal of tissue expander(s) without insertion of prosthesis.
Codes 19364, 19367, 19368 and 19369, which identify breast reconstruction by flap include the dissection and/or excision of flap, the closure of the donor site, the contouring of the breast mound and/or the insertion of a breast implant. Therefore, it is not appropriate to code these services separately, in addition to the breast reconstruction procedure.
Code 19361, which identifies breast reconstruction with latissimus dorsi flap, without prosthetic implant, includes the dissection and/or excision of flap, the closure of the donor site, and the contouring of the breast mound. Any prosthetic implant would be coded separately.
The free flap (19364) and the supercharged TRAM (19368) procedures both include microvascular anastomosis, therefore it is not appropriate to code use of the microsurgical technique with the operating microscope (69990) in addition. A flap is supercharged when an additional artery is dissected with the flap and attached to the recipient site.
Other free flap techniques 19364, include the DIEP, (deep epigastric perforator), a free TRAM ( transverse rectus abdominus myocutaneous), and gluteal free flap according to CPT Asst June 2010.
Breast reconstruction cpt codes by double pedicle TRAM flap (19369) involves taking flaps from both sides of the rectus muscles to create a single (unilateral) breast mound.