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2025 HCPCS code S2068

Breast reconstruction using a DIEP or SIEA flap, including flap harvesting, microvascular transfer, donor site closure, and breast shaping.

Refer to the most current HCPCS coding guidelines for appropriate application of this code.

Modifiers may apply depending on the circumstances of the procedure, such as the use of anesthesia or the location of the service. Always refer to payer-specific guidelines.

Medical necessity is established by the need for breast reconstruction following a mastectomy due to cancer or other medical conditions. Documentation must support the appropriateness of the chosen flap and the overall surgical plan. The need for the surgery should be clearly documented.

The surgical responsibility includes pre-operative planning, surgical procedure, post-operative care, and patient education

IMPORTANT:S2066 (Breast reconstruction with gluteal artery perforator (GAP) flap) and S2067 (Breast reconstruction of a single breast with stacked DIEP and/or GAP flaps) are related codes for alternative breast reconstruction techniques.

In simple words: This code covers a type of breast reconstruction surgery where the surgeon uses tissue from the lower belly to rebuild the breast.It involves connecting blood vessels, closing the belly incision, and shaping the new breast.

This HCPCS code encompasses breast reconstruction utilizing either a deep inferior epigastric perforator (DIEP) flap or a superficial inferior epigastric artery (SIEA) flap.The procedure involves harvesting the chosen flap from the lower abdomen, performing microvascular transfer to connect the flap's blood supply to the recipient site, meticulously closing the donor site, and skillfully shaping the flap to create a natural-looking breast contour. The procedure is performed unilaterally (on one side only).

Example 1: A 45-year-old female patient undergoes a mastectomy for breast cancer.Post-mastectomy, she elects for breast reconstruction using a DIEP flap.Code S2068 would be used to bill for this procedure., A 50-year-old female patient chooses a SIEA flap breast reconstruction following a unilateral mastectomy. Code S2068 would accurately represent this surgical procedure., A 60-year-old female patient has undergone a prior mastectomy and now desires breast reconstruction. She is a suitable candidate for a DIEP flap reconstruction; therefore, code S2068 is appropriate.

Complete surgical notes documenting the type of flap used (DIEP or SIEA), details of the microvascular anastomosis,donor site closure technique, and intraoperative and post-operative complications (if any).Preoperative imaging (e.g., MRI, CT scan), pathology reports confirming the diagnosis, and consent forms are also required.

** This code is not reimbursable by Medicare. Payer-specific policies should be reviewed for coverage and reimbursement. The use of S-codes is temporary and they will eventually be phased out.Always confirm current payer policies for reimbursement before billing.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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