Free Flap Breast Reconstruction

Effective Date: November 15, 2021

Purpose:

To provide billing guidelines for free flap (microvascular) breast reconstructive services. This policy applies to professional claims. This policy applies to participating and non-participating providers.

Scope:

Products included:

  • NJ FamilyCare/Medicaid
  • Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)
  • MTLSS

Definitions:

  • 19364: Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap)
  • S2066*: Breast reconstruction with gluteal artery perforator (GAP) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral
  • S2067*: Breast reconstruction of a single breast with "stacked" deep inferior epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator (GAP) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateral
  • 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

*The temporary HCPCS Level II codes S2066-S2068 were developed by the Blue Cross Blue Shield Association to report services associated with free flap breast reconstruction surgery. At that time, there was no national code to adequately describe free flap breast reconstruction. Since the development of the temporary ‘S’ codes, the American Medical Association (AMA) updated CPT code 19364 to describe free flap breast reconstruction via the techniques described in S2066-S2068 (GAP, DIEP and SIEA flaps). Further clarification was outlined and is summarized below:

  • The AMA states in the December 2011 CPT® Assistant that DIEP flap is properly reported using CPT code 19364 Breast reconstruction with free flap.
  • Breast reconstruction with free flap, is the appropriate code to report free flap breast reconstruction, regardless of the specific free flap used. CPT 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.
  • HCPCS Level II codes S2066-S2068 are never payable by Medicare.

Policy:

For services rendered November 15, 2021 and after, Horizon NJ Health will no longer accept submission of procedure codes S2066-S2068 to report breast reconstruction via a free flap and will require providers to submit CPT code 19364.

Horizon NJ Health will require providers to properly use the coding modifiers -LT, -RT, -50, -62, -80, -81, -82 and -AS on claims for CPT code 19364.

Horizon NJ Health will not consider for reimbursement unbundled or inclusive procedure codes to 19364. Free flap breast reconstruction with CPT code 19364 includes the following services per American Society of Plastic Surgeons (ASPS) and AMA CPT Guidelines:

  • Elevation and transfer of flap
  • Creation of the breast pocket
  • Muscle dissection
  • Closure of donor site
    • Fascial closure with or without mesh
    • Abdominal closure including umbilicoplasty
    • Rectus diastasis repair
  • Breast contouring and inset of the flap
  • Microvascular transfer which includes identification, exploration, transfer and anastomosis of vessels (The microvascular anastomosis includes up to one artery and two veins)
    • CPT code 69990 should not be reported in conjunction with CPT code 19364
  • Rib resection
  • Monitoring of the flap intra-operatively and post-operatively

Claims will be subject to post-service review to ensure compliance with this policy.

Procedure:

Horizon NJ Health will not consider for reimbursement HCPCS level II codes S2066-S2068 as of November 15, 2021.

Horizon NJ Health will consider for reimbursement CPT code 19364.

Horizon NJ Health will not consider for reimbursement procedure codes that are unbundled or inclusive to CPT code 19364 as defined in this policy.

References:

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services

American Medical Association (AMA), December 2011 CPT® Assistant “CPT Assistant Bonus Feature: Special Q&A”

American Society of Plastic Surgeons, 2017, “Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps”

https://www.plasticsurgery.org/documents/medical-professionals/quality-resources/guidelines/guideline-2017-autologous-breast-reconstruction.pdf

American Society of Plastic Surgeons, December 2020, “CPT Corner: A look at new changes coming to E&M and breast coding in 2021”

https://www.plasticsurgery.org/documents/medical-professionals/health-policy/psn-cpt-corner_dec-20.pdf ‌

Limitations and Exclusions:

Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

  • Benefit Limitations;
  • The terms of any applicable provider participation agreement;
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
  • Medical necessity; and
  • Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.