Brst rcnstj 1 pdcl tram flap

CPT 19367 covers breast reconstruction using a pedicle TRAM flap, where the surgeon uses tissue from the lower abdomen (kept attached to its original blood supply) to rebuild the breast. This is a single-stage microsurgical reconstruction typically performed after mastectomy.

Showing rates for

National Average

Base Medicare rate

$1,729.89

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

26.8

PE RVU (NF)

21.77

MP RVU

4.91

Total RVU

53.48

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

NCCI bundling edits

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Billing tips

Document total operative time, flap dimensions, and specific technique (superior vs inferior pedicle) to support high RVU value of 53.48 and differentiate from free TRAM (19364)
Impact: Prevents downcoding to simpler reconstruction codes; protects full $1729.89 Medicare payment
Bill separately for abdominal wall closure with mesh reinforcement (49568) when performed, as this is not bundled with 19367
Impact: Additional $300-500 reimbursement when mesh placement medically necessary and documented
Verify payer-specific bilateral modifier policies before using modifier 50; some payers require two line items with RT/LT instead
Impact: Incorrect bilateral billing format causes denials requiring resubmission and 30-60 day payment delays
For immediate reconstruction (performed same day as mastectomy by different surgeon), ensure both surgeons document as co-surgeons or use modifier 62 appropriately
Impact: Each surgeon receives 62.5% of allowed amount ($1081.18 Medicare) rather than assistant surgeon rate of 16%
Submit delayed reconstruction claims with diagnosis codes confirming personal history of breast cancer (Z85.3) or genetic susceptibility (Z15.01) to support medical necessity
Impact: Reduces denial rate by 40-60% compared to claims without clear reconstruction indication
Do not bill debridement (11042-11047) or minor revisions performed within the 90-day global period separately unless returning to OR under anesthesia
Impact: Prevents $150-400 in audit recoupments for bundled services

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 19367 in 2025?

The 2025 Medicare national average payment for CPT 19367 is $1729.89 for both facility and non-facility settings. This is based on 53.48 total RVUs (26.8 work + 21.77 PE + 4.91 MP) multiplied by the 2025 conversion factor of $32.3465.

What is the difference between CPT 19367 and 19364?

CPT 19367 is for pedicle TRAM flap reconstruction where abdominal tissue remains attached to its original blood supply, while 19364 describes free TRAM flap where vessels are completely divided and reconnected using microsurgical techniques. The pedicle technique (19367) has slightly lower RVUs (53.48 vs 58.92) and does not require microvascular anastomosis documentation.

Can CPT 19367 be billed bilaterally with modifier 50?

Yes, bilateral pedicle TRAM flap reconstruction can be billed with modifier 50, though this is rare as the pedicle technique typically limits tissue availability to one side. Verify payer-specific policies as some require two separate line items with RT/LT modifiers instead of modifier 50. Bilateral procedures typically reimburse at 150% of the unilateral rate.

How many RVUs is CPT code 19367 worth in 2025?

CPT 19367 has 53.48 total RVUs in 2025, consisting of 26.8 work RVUs, 21.77 practice expense RVUs (both facility and non-facility), and 4.91 malpractice RVUs according to the CMS Physician Fee Schedule RVU25A released December 23, 2024.

Can 19367 be billed on the same day as a mastectomy?

Yes, immediate breast reconstruction (19367) performed the same day as mastectomy is separately billable and medically appropriate. If performed by the same surgeon, no modifier is typically needed as these are distinct procedures. If by different surgeons during same session, use modifier 62 for co-surgery. Documentation must clearly delineate both procedures separately.

What documentation is required to bill CPT 19367?

Required documentation includes: mastectomy indication/history, confirmation of pedicle technique with intact vascular supply, flap dimensions, laterality, donor site closure method, operative time, and clear distinction from free flap technique. Photographic documentation is standard of care. Missing any element increases audit and denial risk significantly.

Is mesh placement separately billable with CPT 19367?

Yes, abdominal wall mesh reinforcement (CPT 49568) is separately billable when medically necessary and documented, as it is not bundled with 19367. This typically adds $300-500 to reimbursement. Documentation must justify medical necessity (e.g., large fascial defect, hernia risk) rather than routine closure technique.