DIEP Flap Breast Reconstruction

CPT 19364
Approach Microsurgical
Add-on / Variant CPTs
  • 19367 — Breast reconstruction with transverse rectus abdominis musculocutaneous flap
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:

[Attending name], MD

First Assistant:

[Resident/Fellow/PA name]

Anesthesia:

General endotracheal
Patient supine. Two-team approach. Operating microscope for microvascular anastomosis.

Indications:

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.

Findings:

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 [third / fourth] intercostal space.

Description of Procedure:

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 [third / fourth] intercostal cartilage was excised sharply to expose the internal mammary artery and vein. Vessels isolated under loupe magnification.
MICROVASCULAR ANASTOMOSIS: Under the operating microscope, end-to-end anastomosis performed between the DIEP pedicle artery and internal mammary artery with [9-0 / 8-0] nylon interrupted sutures. End-to-end venous anastomosis performed with [3-mm] microvascular coupler device. 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.

Complications:

None

Specimens:

None

Estimated Blood Loss:

[200-400] mL

Drains:

[Two] JP drains: [one] at flap, [one] at abdominal donor site

Disposition:

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 [third / fourth] 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: Third/fourth intercostal cartilage excised. 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. 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
.TODAY
Variants

TRAM flap (pedicled)

CPT 19367. Pedicled on superior epigastric vessels. Sacrifice of rectus muscle segment. Document muscle preservation attempts and fascial closure.

Bilateral DIEP

Two separate flaps for bilateral reconstruction. Document bilateral pedicle harvest, recipient vessel preparation, and anastomosis for each side.

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
  • State pedicle artery and vein size at takedown
  • Microvascular anastomosis: technique (interrupted vs. coupler), suture size, clamp time
  • Flap perfusion assessment: Doppler signal, color, capillary refill at completion
  • Abdominal fascial closure technique (critical for hernia prevention)
  • Postoperative flap monitoring protocol must be established
Billing Tips
  • 19364 (free flap breast reconstruction, 41.52 wRVU) covers DIEP, SIEA, and all free tissue transfer for breast reconstruction. It is the highest-weighted breast reconstruction code.
  • TRAM flap alternatives: 19367 (pedicled, 26.13 wRVU), 19368 (pedicled + supercharge anastomosis, 33.05 wRVU), 19369 (bipedicled, 30.53 wRVU). 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: if a microsurgery co-surgeon performs the vessel anastomosis, both surgeons bill 19364 with modifier -62 (co-surgery). Document distinct roles in the operative note.
  • Bilateral reconstruction: each breast is billed separately. Append -RT/-LT. Bilateral reimbursement is 150% of the single-procedure rate.
  • Recipient site vessel preparation (e.g., internal mammary artery dissection) is bundled into 19364. Do not bill separately.
  • Document flap harvest dimensions, recipient vessels used, ischemia time, and method of anastomosis (end-to-end vs end-to-side) for both clinical accuracy and coding defensibility.