Nipple/areola reconstruction

CPT code 19350 covers the surgical reconstruction of the nipple and areola, typically performed after mastectomy or breast reconstruction. This procedure recreates the natural appearance of the nipple-areola complex using local tissue flaps, skin grafts, or tattooing techniques.

Showing rates for

National Average

Base Medicare rate

$814.48

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

9.11

PE RVU (NF)

14.37

MP RVU

1.7

Total RVU

25.18

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Always link 19350 to the original mastectomy diagnosis code (C50.x or Z90.1x) rather than cosmetic codes to establish medical necessity
Impact: Prevents automatic denials; difference between $0 and full $814.48 reimbursement for non-facility claims
Bill bilateral procedures (modifier 50) on a single line rather than two separate lines with RT/LT modifiers
Impact: Ensures proper 150% reimbursement ($1,221.72 vs potential $814.48 if only one side is paid)
For areolar tattooing performed separately from nipple reconstruction, use 11920-11922 instead of 19350
Impact: Prevents downcoding; tattooing alone is not nipple reconstruction and would be denied under 19350
Document the time interval from previous breast reconstruction procedure (typically 19357, 19361, 19364, or 19366) to support modifier 58 if within global period
Impact: Avoids denials for staged procedures; many insurers require 3-6 month interval documentation
Submit photographs (with patient consent) showing post-mastectomy status and reconstruction stages to prove medical necessity for initial claims review
Impact: Reduces prior authorization denials by approximately 40-60% based on specialty society data
Verify Women's Health and Cancer Rights Act (WHCRA) coverage with commercial payers before surgery; this federal law mandates coverage
Impact: Strengthens appeals for denied claims; WHCRA requires coverage of all stages of breast reconstruction including nipple-areola

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Frequently asked questions

What is the CPT code 19350 used for?

CPT 19350 is used for surgical reconstruction of the nipple and areola, typically as the final stage of breast reconstruction following mastectomy. This procedure creates a natural-appearing nipple-areola complex using local tissue flaps, skin grafts, or a combination of techniques.

How much does Medicare pay for CPT 19350 in 2025?

Medicare pays $814.48 for CPT 19350 in non-facility settings and $663.10 in facility settings based on the 2025 national average rates. Actual reimbursement varies by geographic location based on local wage indexes and GPCI adjustments.

Is nipple reconstruction covered by insurance?

Yes, nipple-areola reconstruction following mastectomy is covered by Medicare and must be covered by commercial insurers under the federal Women's Health and Cancer Rights Act (WHCRA). Coverage requires documentation of previous mastectomy and breast reconstruction, establishing medical necessity rather than cosmetic intent.

Can CPT 19350 be billed bilaterally?

Yes, when nipple-areola reconstruction is performed on both breasts during the same operative session, bill CPT 19350 with modifier 50 for bilateral procedure. This typically results in 150% of the unilateral rate, or approximately $1,221.72 for Medicare non-facility settings.

What is the global period for CPT 19350?

CPT 19350 has a 90-day global period, meaning routine follow-up care for 90 days after surgery is included in the reimbursement. Any unrelated procedures or complications requiring return to the OR during this period require appropriate modifiers (78, 79) for separate payment.

What diagnosis codes support medical necessity for 19350?

Medical necessity for 19350 is established with personal history of breast cancer (Z85.3), genetic susceptibility to breast cancer (Z15.01), acquired absence of breast (Z90.1x), or active breast cancer codes (C50.x). These must link to previous mastectomy to demonstrate reconstructive rather than cosmetic intent.

How long after breast reconstruction can you bill CPT 19350?

CPT 19350 is typically performed 3-6 months after breast mound reconstruction to allow for healing and proper positioning. When billed within the 90-day global period of the breast reconstruction procedure (19357, 19361, 19364, 19366), modifier 58 must be appended to indicate a planned staged procedure for proper reimbursement.