Free Flap Breast Reconstruction

Reimbursement Policy:

Free Flap Breast Reconstruction

Effective Date:

November 15, 2021

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Last Revised Date:

February 22, 2024

Policy Last Reviewed Date:

February 22, 2024

Scope:

All products are included, except

• Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap)
• ITS Home Par
• ITS Host Medicare Advantage (PPO OON)
• MPL
• COB

All Insured and Administrative Services Only (ASO) accounts are included.

Purpose:

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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.

Definitions:

• Procedure Code 19364: Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap)
• Procedure Code 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
• Procedure Code 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
• Procedure 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
  • *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 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 American Medical Association (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 not payable by Medicare

Policy:

Horizon BCBSNJ does not accept HCPCS Level II S2066-S2068 to report breast reconstruction via a free flap and requires providers to submit CPT code 19364 instead.

Horizon BCBSNJ allows providers to properly append the applicable coding modifiers for CPT code 19364.

Horizon BCBSNJ shall 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

Procedure:

Horizon BCBSNJ shall deny HCPCS level II codes S2066-S2068.

Horizon BCBSNJ shall consider for reimbursement CPT code 19364 when appropriate.

Horizon BSBCNJ shall deny procedure codes that are unbundled or inclusive to CPT code 19364 as defined in this policy.

Limitations and Exclusions:

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While reimbursement is considered, payment determination is subject to, but not limited to:

• The terms and conditions of the applicable health benefit plan.
• The medical necessity of the services provided.
• The members’ eligibility at the time services are rendered.
• The applicable Provider Participation Agreement.
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity.
• Mandated or legislative required criteria will always supersede.

Resources:

American Medical Association (AMA), Current Procedural Terminology (CPT®) 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

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.

History:

07/28/2021: Policy approved 02/22/2024: Updated scope section. Verbiage under policy was amended to remove effective date.

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