Wiki Latissimus dorsi flap and tissue expander

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Breast Reconstruction.......I am having a problem with an insurance paying for the tissue expander when we do a latissimus dorsi flap. Is anyone else having the same problem? The codes are 19361 (Breast reconstruction with latissimus dorsi flap, without prosthetic implant) and 19357 (Breast reconstruction with tissue expander). Please advise.

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Tina
 
It's funny that you bring this up..We just called MMO in the last week, on one and said that they won't pay for both because of the CCI. But I have the CPT corner and it says that you should be able to put a 59 mod on 19357. I talked to the doctor and we are going to try this. He doesn't want to make the patient go through two different surgeries, so he is willing to take the write off if he has to.

I just don't understand why they would want to pay for two different surgeries. It would save them a lot of money to allow them together.

Terri
 
This IS confusing

NOT my area of expertise, but this really got me thinking.

I guess I can see the payer's point of view ... you did not reconstruct the breast TWICE. And both codes include the reconstruction part.

Of course if you did a reconstruction with flap on one breast, and reconstruction with expander on the other breast then no problem - you clearly have two different surgical sites and you could use LT and RT modifiers.

It would be nice if we had a code for just the insertion of the tissue expander. Unfortunately CPC does not allow you to code 11960 with the breast reconstruction codes. Maybe they need to develop an add-on code for this?

I wonder if 11961[M22] mod would work to show the additional effort of placing the expander (and subsequent expansion).

Don't mean to confuse the issue ... just "typing out loud."

F Tessa Bartels, CPC, CEMC
 
latissimus dorsi flap and tissue expander

I know this post was back in 2009 but I have this same issue with my claims. My physician performs the latissimus dorsi flap...and then tissue expander for the implants (in the future).

These are both "breast reconstruction" procedures but are not identical, nor are mutually exclusive. The current NCCI version does not have a CCI relationship for these codes anymore. Maybe back in 2009, there was. And that is probably why some insurance companies are still stuck in that idea that they are bundled.

The surgeon has to first perform 19361 to create the chest wall muscle...the description of this CPT code 19361 stop right there...when the physician creates the pocket from the created muscle to insert the tissue expander or implants, that is another procedure (19357) independent from 19361...

19357 also includes subsequent expansion which 19361 do not have in its description.

Marie Laygo
 
latissimus dorsi flap and tissue expander

I know this post was back in 2009 but I have this same issue with my claims. My physician performs the latissimus dorsi flap...and then tissue expander for the implants (in the future).

These are both "breast reconstruction" procedures but are not identical, nor are mutually exclusive. The current NCCI version does NOT show a CCI relationship for these codes anymore. Maybe back in 2009, there was. And that is probably why some insurance companies are still stuck in that idea that these two codes must be bundled.

The surgeon has to first perform 19361 to create the chest wall muscle...the description of this CPT code 19361 stop right there...when the physician creates the pocket from the created muscle to insert the tissue expander or implants, that is another procedure (19357) independent from 19361...

19357 also includes subsequent expansion which 19361 do not have in its description.

Marie Laygo
 
Lat Flap with tissue expanders

Is anyone continuing to have problems with ins bundling the Lat Flap and breast tissue expanders 19361 and 19357? Any solutions?
 
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