Brst rcnstj free flap

CPT 19364 covers breast reconstruction using tissue taken from another part of the patient's body (free flap), where the tissue is completely disconnected and then reattached using microsurgery to restore blood flow. This is a complex reconstructive procedure typically performed after mastectomy.

Showing rates for

National Average

Base Medicare rate

$2,648.21

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

42.58

PE RVU (NF)

31.31

MP RVU

7.98

Total RVU

81.87

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

NCCI bundling edits

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Billing tips

Document total operative time and specific microsurgical anastomosis time separately, including vessel sizes and number of anastomoses performed
Impact: Essential for modifier 22 justification which can increase reimbursement by $500-$1,300 for unusually complex cases
Bill for the donor site closure separately using appropriate codes (e.g., 15734 for muscle/myocutaneous flap) as these are not bundled with 19364
Impact: Additional $400-$800 in reimbursement for donor site procedures that are separately reportable
Verify medical necessity documentation includes failed/contraindicated implant reconstruction or patient factors making free flap preferred option
Impact: Prevents denials for lack of medical necessity; appeals without this documentation have less than 30% success rate
For bilateral procedures, confirm payer-specific bilateral surgery policies before submitting; some require modifier 50, others prefer two line items with RT/LT
Impact: Incorrect bilateral billing can result in 50% underpayment ($2,648 loss) or claim rejection requiring resubmission delays
Submit pre-authorization with photos, clinical notes documenting mastectomy, and surgeon credentials showing microsurgical training
Impact: Reduces denial rate from approximately 25% to under 5% for this high-value procedure
Use ICD-10 code Z42.1 (encounter for breast reconstruction following mastectomy) as primary diagnosis with original cancer diagnosis as secondary
Impact: Proper diagnosis sequencing supports medical necessity and Women's Health and Cancer Rights Act coverage requirements

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Frequently asked questions

What is the Medicare reimbursement for CPT 19364 in 2025?

The 2025 Medicare national average reimbursement for CPT 19364 is $2,648.21 for both facility and non-facility settings. This is based on 81.87 total RVUs (42.58 work RVU, 31.31 PE RVU, 7.98 MP RVU) multiplied by the 2025 conversion factor of $32.3465. Actual payment may vary by geographic location based on locality adjustments.

How do you bill for bilateral breast reconstruction with free flaps?

For bilateral free flap reconstruction, most payers require modifier 50 appended to CPT 19364, which typically reimburses at 150% of the unilateral rate ($3,972.32 for Medicare). Some payers prefer two line items with RT and LT modifiers. Always verify payer-specific bilateral surgery policies before submission as requirements vary significantly.

Can you bill CPT 19364 with donor site closure codes?

Yes, donor site closure codes (such as 15734 for muscle/myocutaneous flap or 15738 for fascial flap closure) are separately reportable and not bundled with CPT 19364. The operative report must clearly document the donor site procedure as a distinct service requiring separate dissection and closure techniques. These additional codes can add $400-$800 to total reimbursement.

What documentation is required to prevent denials for CPT 19364?

Essential documentation includes mastectomy history with cancer diagnosis or prophylactic indication, clinical rationale for choosing free flap over implants or pedicled flaps, detailed operative report documenting microsurgical anastomosis (including vessel sizes and number of anastomoses), operating microscope usage, donor site location, and post-operative flap monitoring plan. Pre-authorization with surgeon credentials showing microsurgical training significantly reduces denial risk.

What is the difference between CPT 19364 and 19367?

CPT 19364 describes breast reconstruction using a free flap where tissue is completely detached and blood vessels are reconnected using microsurgery. CPT 19367 describes reconstruction using a pedicled TRAM flap where tissue remains partially attached to its original blood supply. The free flap (19364) requires microsurgical skills and has higher reimbursement ($2,648.21 vs lower for pedicled), but documentation must clearly demonstrate complete vascular division and reanastomosis.

Does CPT 19364 require prior authorization?

Most commercial payers and Medicare Advantage plans require prior authorization for CPT 19364 due to the high cost and complexity. Traditional Medicare does not require prior authorization but may conduct post-payment review. Authorization requests should include clinical notes, mastectomy documentation, photos, medical necessity justification, and surgeon credentials demonstrating microsurgical training to improve approval rates.

How many RVUs is CPT 19364 worth in 2025?

CPT 19364 has a total of 81.87 RVUs in 2025, consisting of 42.58 work RVUs (physician effort), 31.31 practice expense RVUs (both facility and non-facility), and 7.98 malpractice RVUs. This is one of the higher RVU values in reconstructive surgery, reflecting the complexity and duration of microsurgical breast reconstruction.