My surgeon wants to code surgical prep codes (15002) when doing DEIP flaps - I have never heard of doing this. There isn't a CCI edit, they can be coded together, but I feel like the code 19364 covers the prep. 
Any input would be appreciated!!
Here is the op-note:
RECIPIENT SITE PREPARATION
The proposed breast footprint was confirmed. The existing mastectomy scar was incorporated into the incision for exposure. I raised superior and inferior skin flaps in the pre-pectoral plane along the entire footprint of the breast. I shaped the pocket carefully (using 0-Maxon to reinforce the lateral and inframammary breast folds as needed). A 15-Fr blake drain was placed in the lateral breast and secured with 3-0 Nylon suture.
The inferior native mastectomy skin was removed and sent for pathology, and was replaced ultimately with flap skin paddle from abdomen
The pectoral muscle was exposed. The {4th rib was identified. The overlying muscle was split along its fibers with directed dis-origination of fibers along the sternum to allow for exposure of the underlying rib and adjacent intercostal spaces. Perichondrium was sharply incised and lifted off the underlying cartilaginous rib using Freer elevator. Doyen rib raspatory completed elevation of the perichondrium off of the deep surface. With the deep surface protected, the cartilage was sharply incised and removed back to the sternocostal junction using rongeur. Starting laterally, the overlying perichrondrial layer was incised and lifted in a medial direction toward the internal mammary vessels, creating a window for access to the recipient vessels. The vessels (1 IMA, 1 IMV) were identified in their expected location and dissected under loupe magnification, controlling side branches with bipolar cautery and microvascular clips. Further proximal and distal exposure was accomplished by excising intercostal muscle. Using the operating microscope, Acland microvascular clamps were applied to the IMA and IMV. Clips were applied distally, and the vessels were transected with straight micro-scissors. Adventitia was cleared, no intimal damage was identified, and IMA inflow was confirmed.
FLAP ELEVATION
MICROSURGERY, INSET & CLOSURE
The chest vessels had previously been prepared as described. The recipient artery and vein were further prepared under the operating microscope, clipped and divided distally, with Acland clamps placed proximally.
Once we were ready for flap transfer, the flap vessels were ligated at their origin from the external iliac vessels, placing double clips on the origin stumps. The flap was brought up to the chest and secured in place with staples. Using the operating microscope, the flap vessels were prepared, dissecting away peri-adventitial tissues for appropriate anastomosis. The vessels were gently dilated and irrigated with heparinized saline solution. Using a vessel sizer, the flap vein and recipient vein were measured for a 2.5-mm diameter coupler. The selected Synovis coupler was brought onto the field. The flap vein was positioned onto the coupler pins, followed by the recipient vein. Visual inspection revealed no intimal injury or intraluminal debris. The coupler was brought into apposition and released.
Attention was then turned to the arterial anastomosis. A double-opposing A3 Acland clamp was used to bring the flap artery and the recipient artery into apposition. Anastomosis proceeded with 9-0 Nylon suture in interrupted fashion, taking care to avoid any backwalling or injury of the intima. Once this was complete, the Acland clamps were first released from the vein to ascertain the degree of baseline backflow, and then from the artery. The pedicle was noted to be pulsatile all the way to the perforator entry into the flap, with audible Doppler signals identified on the skin paddle.
The pedicle was positioned to avoid any kinks or twists. The flap was positioned within the pocket, shaped, and temporarily secured with staples. Areas for de-epithelialization were marked along the flap. De-epithelialization was completed using facelift scissors and 10-blade. The site was irrigated, and closure proceeded with 3-0 Monocryl interrupted deep dermal sutures followed by 4-0 Monocryl running subcuticular suture. The incisions were dressed with Steri-Strips. Cutaneous arterial signals were identified with handheld Doppler and marked with a 5-0 Nylon suture.
Please note a modifier 22 is being applied to this case given the required perforator dissection, which added at least 50% increased time and complexity to the case compared to a standard free TRAM.
Any input would be appreciated!!
Here is the op-note:
RECIPIENT SITE PREPARATION
The proposed breast footprint was confirmed. The existing mastectomy scar was incorporated into the incision for exposure. I raised superior and inferior skin flaps in the pre-pectoral plane along the entire footprint of the breast. I shaped the pocket carefully (using 0-Maxon to reinforce the lateral and inframammary breast folds as needed). A 15-Fr blake drain was placed in the lateral breast and secured with 3-0 Nylon suture.
The inferior native mastectomy skin was removed and sent for pathology, and was replaced ultimately with flap skin paddle from abdomen
The pectoral muscle was exposed. The {4th rib was identified. The overlying muscle was split along its fibers with directed dis-origination of fibers along the sternum to allow for exposure of the underlying rib and adjacent intercostal spaces. Perichondrium was sharply incised and lifted off the underlying cartilaginous rib using Freer elevator. Doyen rib raspatory completed elevation of the perichondrium off of the deep surface. With the deep surface protected, the cartilage was sharply incised and removed back to the sternocostal junction using rongeur. Starting laterally, the overlying perichrondrial layer was incised and lifted in a medial direction toward the internal mammary vessels, creating a window for access to the recipient vessels. The vessels (1 IMA, 1 IMV) were identified in their expected location and dissected under loupe magnification, controlling side branches with bipolar cautery and microvascular clips. Further proximal and distal exposure was accomplished by excising intercostal muscle. Using the operating microscope, Acland microvascular clamps were applied to the IMA and IMV. Clips were applied distally, and the vessels were transected with straight micro-scissors. Adventitia was cleared, no intimal damage was identified, and IMA inflow was confirmed.
FLAP ELEVATION
MICROSURGERY, INSET & CLOSURE
The chest vessels had previously been prepared as described. The recipient artery and vein were further prepared under the operating microscope, clipped and divided distally, with Acland clamps placed proximally.
Once we were ready for flap transfer, the flap vessels were ligated at their origin from the external iliac vessels, placing double clips on the origin stumps. The flap was brought up to the chest and secured in place with staples. Using the operating microscope, the flap vessels were prepared, dissecting away peri-adventitial tissues for appropriate anastomosis. The vessels were gently dilated and irrigated with heparinized saline solution. Using a vessel sizer, the flap vein and recipient vein were measured for a 2.5-mm diameter coupler. The selected Synovis coupler was brought onto the field. The flap vein was positioned onto the coupler pins, followed by the recipient vein. Visual inspection revealed no intimal injury or intraluminal debris. The coupler was brought into apposition and released.
Attention was then turned to the arterial anastomosis. A double-opposing A3 Acland clamp was used to bring the flap artery and the recipient artery into apposition. Anastomosis proceeded with 9-0 Nylon suture in interrupted fashion, taking care to avoid any backwalling or injury of the intima. Once this was complete, the Acland clamps were first released from the vein to ascertain the degree of baseline backflow, and then from the artery. The pedicle was noted to be pulsatile all the way to the perforator entry into the flap, with audible Doppler signals identified on the skin paddle.
The pedicle was positioned to avoid any kinks or twists. The flap was positioned within the pocket, shaped, and temporarily secured with staples. Areas for de-epithelialization were marked along the flap. De-epithelialization was completed using facelift scissors and 10-blade. The site was irrigated, and closure proceeded with 3-0 Monocryl interrupted deep dermal sutures followed by 4-0 Monocryl running subcuticular suture. The incisions were dressed with Steri-Strips. Cutaneous arterial signals were identified with handheld Doppler and marked with a 5-0 Nylon suture.
Please note a modifier 22 is being applied to this case given the required perforator dissection, which added at least 50% increased time and complexity to the case compared to a standard free TRAM.