How To Use CPT Code 19369

CPT code 19369 describes the procedure for breast reconstruction with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 19369?

CPT code 19369 is used to describe the procedure for breast reconstruction with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap. This involves the artificial creation of a breast contour by harvesting a flap of skin, fat, and transverse rectus abdominis muscle from both sides of the lower abdomen. The flap is then sutured to the location of the original breast to restore the cosmetic appearance following breast removal surgery or to repair a defect.

2. Official Description

The official description of CPT code 19369 is: ‘Breast reconstruction with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap, including harvesting of the flap, closure of the donor site, insetting, and shaping of the flap.’

3. Procedure

The procedure for breast reconstruction with bipedicled TRAM flap involves several steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider creates a receptacle for receiving the supplementary tissue, such as by opening the mastectomy scar.
3. The provider dissects and elevates the skin, fat, and transverse rectus abdominis muscle tissue from the peri- and infraumbilical area.
4. The provider dissects graft tissue from both sides of the lower abdomen, retaining blood vessel and nerve attachments to each pedicle of the graft.
5. A subcutaneous tunnel is created, and the bipedicle flap is transposed from the abdominal wall to the mastectomy site.
6. The provider trims, sculpts, and sutures the flap to reconstruct the breast, using the abdominal epidermis to create the breast skin surface.
7. Hemostasis is achieved, and the operative site is closed in layers.

4. Qualifying circumstances

Breast reconstruction with bipedicled TRAM flap is performed for patients who require the restoration of breast contour following surgical removal or to repair a defect. This procedure is typically performed by a qualified provider who has the necessary expertise in performing breast reconstruction surgeries.

5. When to use CPT code 19369

CPT code 19369 should be used when breast reconstruction is performed using a bipedicled TRAM flap. This code specifically covers the harvesting of the flap, closure of the donor site, insetting, and shaping of the flap. It is important to ensure that the procedure performed meets the criteria outlined in the official description of the code.

6. Documentation requirements

To support a claim for CPT code 19369, the provider must document the following information:

• Patient’s diagnosis or indication for breast reconstruction
• Description of the procedure performed, including details of the flap harvesting, closure of the donor site, insetting, and shaping of the flap
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT code 19369, it is important to ensure that the procedure performed meets the criteria outlined in the official description. The code should be reported for breast reconstruction with bipedicled TRAM flap, including all the specified components. It is also important to follow any specific billing guidelines provided by the payer or relevant coding guidelines.

8. Historical information

CPT code 19369 was added to the Current Procedural Terminology system on January 1, 1995. There have been no updates or changes to the code since its addition.

9. Similar codes to CPT 19369

There are several similar codes to CPT code 19369 that describe different types of breast reconstruction procedures. These include:

• CPT 19361: Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle
• CPT 19364: Breast reconstruction with free flap
• CPT 19367: Breast reconstruction with other technique
• CPT 19368: Breast reconstruction with latissimus dorsi flap

9. Examples

1. A patient undergoes breast reconstruction with bipedicled TRAM flap following a mastectomy.
2. A provider performs breast reconstruction with bipedicled TRAM flap to repair a defect caused by trauma.
3. A patient undergoes breast reconstruction with bipedicled TRAM flap after previous failed breast reconstruction attempts.
4. A provider performs breast reconstruction with bipedicled TRAM flap for a patient with a congenital breast deformity.
5. A patient undergoes breast reconstruction with bipedicled TRAM flap following breast removal due to cancer.
6. A provider performs breast reconstruction with bipedicled TRAM flap to correct asymmetry in breast size and shape.
7. A patient undergoes breast reconstruction with bipedicled TRAM flap after undergoing prophylactic mastectomy.
8. A provider performs breast reconstruction with bipedicled TRAM flap for a patient with Poland syndrome.
9. A patient undergoes breast reconstruction with bipedicled TRAM flap following breast removal due to infection.
10. A provider performs breast reconstruction with bipedicled TRAM flap to improve the cosmetic appearance of the breast.