Brst rcnstj latsms drsi flap

CPT 19361 covers breast reconstruction using a latissimus dorsi flap, where muscle and tissue from the patient's back are moved to rebuild the breast, typically after mastectomy. This is a complex surgical procedure requiring specialized plastic surgery expertise.

Showing rates for

National Average

Base Medicare rate

$1,523.84

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

23.36

PE RVU (NF)

19.4

MP RVU

4.35

Total RVU

47.11

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

NCCI bundling edits

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Billing tips

Document total operative time, blood loss, and specific anatomical challenges in the operative report to support modifier 22 claims when appropriate
Impact: Can increase reimbursement by $304.77 to $761.92 (20-50% above base rate) for legitimately complex cases with proper documentation
Bill separately for tissue expander or implant placement (CPT 19340 or 19342) when used in combination with latissimus flap for adequate volume, as these are not bundled
Impact: Additional $400-800 in reimbursement depending on implant type and payer; requires clear documentation that both procedures were medically necessary
Verify prior authorization requirements 3-4 weeks before surgery, as most commercial payers require pre-certification for autologous reconstruction despite WHCRA mandates
Impact: Prevents complete claim denial; retroactive authorizations often reduced by 50% or denied entirely, risking $1523.84 loss
Submit claims with diagnosis codes indicating cancer history (Z85.3) or genetic predisposition (Z15.01) rather than cosmetic codes to ensure medical necessity determination
Impact: Difference between full payment and complete denial; improper diagnosis coding is the #1 reason for reconstruction denials
For bilateral procedures, verify payer-specific bilateral surgery rules before submitting; some require modifier 50, others require two line items with RT/LT
Impact: Incorrect bilateral billing format causes processing delays of 30-60 days and potential underpayment of $761.92 if processed as unilateral
When performed with immediate mastectomy by different surgeon, coordinate billing to ensure both surgeons use appropriate modifiers (62 if co-surgery, or separate codes if sequential)

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Frequently asked questions

What is the Medicare reimbursement rate for CPT code 19361 in 2025?

The 2025 Medicare national average reimbursement for CPT 19361 is $1523.84 for both facility and non-facility settings. This rate is based on a total RVU of 47.11 multiplied by the 2025 conversion factor of 32.3465. Local Medicare Administrative Contractors (MACs) may have slightly different rates based on geographic adjustments.

Can CPT 19361 be billed with a mastectomy code on the same date of service?

Yes, CPT 19361 can and should be billed separately when breast reconstruction with latissimus dorsi flap is performed during the same operative session as mastectomy. These are distinct procedures with separate CPT codes (mastectomy codes 19303-19307), and the Women's Health and Cancer Rights Act (WHCRA) mandates coverage for reconstruction following mastectomy. No modifier 59 is typically required as there is no NCCI edit bundling these procedures.

What is the work RVU for CPT code 19361?

CPT code 19361 has a work RVU of 23.36 for 2025, reflecting the significant physician work involved in harvesting and transferring the latissimus dorsi flap. The total RVU is 47.11, which includes work RVU (23.36), practice expense RVU (19.4), and malpractice RVU (4.35).

How should bilateral latissimus dorsi breast reconstruction be coded?

Bilateral latissimus dorsi breast reconstruction should be coded with CPT 19361 and modifier 50 (bilateral procedure) on a single line, or as two separate line items with modifiers RT and LT, depending on payer preference. Medicare typically accepts modifier 50 with 150% payment. Always verify payer-specific bilateral surgery rules before submitting claims.

Is prior authorization required for CPT 19361?

Most commercial insurance payers require prior authorization for CPT 19361 despite federal WHCRA mandates covering post-mastectomy reconstruction. Medicare typically does not require prior authorization but may conduct retrospective medical necessity reviews. Always verify authorization requirements 3-4 weeks before scheduled surgery to prevent claim denials.

What diagnosis codes support medical necessity for CPT 19361?

Primary diagnosis codes supporting medical necessity include Z42.1 (encounter for breast reconstruction following mastectomy), Z85.3 (personal history of malignant neoplasm of breast), C50.x (active breast cancer), and Z15.01 (genetic susceptibility to breast cancer for prophylactic cases). Avoid cosmetic diagnosis codes such as N64.82 or N62, which will result in denials.

Can CPT 19361 be billed with breast implant placement codes?

Yes, CPT 19361 can be appropriately billed with implant placement codes (19340 for tissue expander or 19342 for breast implant) when the latissimus flap alone does not provide adequate volume and supplemental implant is medically necessary. These codes are not bundled by NCCI. Documentation must clearly indicate medical necessity for both the flap and the implant component, with explanation of why flap alone was insufficient.