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Billing Manager - use this code

  1. #1
    Smile Billing Manager - use this code
    Medical Coding Books
    Need help with code 15734. when our surgeon bills this code with any other procedure, most insurances deny stating cannot be billed with other procedure on the same day. I cannot find any LCD's on this procedure and CCI edits do not indicate that this is global with any of the procedures he billed. For instance, billed 19361, 19340 and 15734. first two codes were paid and 15734 denied. Can anyone tell me how I am to use this code? Should the surgeon be using a tissue transfer code instead (14300)?

  2. #2
    Doesn't 19361 include the flap?

  3. #3
    Sioux Falls South Dakota
    Per CPT Assistant August 2005:


    CPT breast reconstruction codes 19361, 19364, 19367, 19368, and 19369 are global codes and include the following elements:

    Elevation and transfer of the flap
    Closure of the donor site
    Breast contouring
    Insertion of breast implant or prosthesis, when performed
    Code 19361, Breast reconstruction with latissimus dorsi flap, with or without prosthetic implant, describes breast reconstruction using a flap that includes the latissimus dorsi, a large muscle on the back. The muscle and overlying skin are elevated and passed through a tunnel under the skin to the chest where it is placed between the chest muscle and skin to form the new breast mound.

    Therefore, the flap shouldn't be billed separately.

    Hope this helps.
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

  4. #4
    Default muscle flaps
    Thank you for your help. I did think that the flap was included, however, when our surgeon also bill for say a hernia repair, 15734 is also denied. They only pay for the hernia repair. What do we do in that case?

  5. #5
    Sioux Falls South Dakota
    I've not heard of a flap being billed with hernia repair. Which hernia repair codes are being used - possibly post a redacted op note?
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

  6. Default
    Without seeing the operative note, in the scenario above (CPT 19361, 19340 and 15734)my guess is that they are bundling CPT 15734 to CPT 19361. Is there an additional flap being raised and inserted besides the latissimus? I've also billed separation of parts (CPT 15734) with a hernia repair (e.g. CPT 49560) and have not had any problems getting paid.

  7. #7
    Default Flaps
    Yes, he noted back to me that he is billing for the pectorilis flap in addition to latissimus or serratus flap in addition to the pectorilis. How do you bill in that case?

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