Cracking the Code

Coding All Components of a DIEP Procedure

A deep inferior epigastric perforator (DIEP) flap procedure is a type of breast reconstruction surgery that does not require incisions to be made within the muscles. Instead, surgeons use a free flap of complete tissue from the blood vessels (perforators), skin, and fat from the lower abdomen. Sometimes, a surgeon may complete a mastectomy prior to completing a DIEP procedure. Other times, a surgeon may remove a tissue expander prior to completing a DIEP procedure.

When coding DIEP procedures, it is important for medical coders to read the entire operative report. Be sure to thoroughly review each sentence in the provider’s note so that all components are fully captured.

Q: A surgeon removes a tissue expander from the right breast before completing a bilateral DIEP breast reconstruction procedure.
A: 0HRV077, Replacement of Bilateral Breast using Deep Inferior Epigastric Artery Perforator Flap, Open Approach; 0HPT0NZ, Removal of Tissue Expander from Right Breast, Open Approach
CPT 19364-50; 11971-RT
Reference: AHA Coding Clinic Third Quarter 2018: DIEP Flap Breast
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