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CPT code 19368 covers breast reconstruction using a pedicle TRAM flap procedure, where tissue from the abdomen is used to rebuild the breast while maintaining its original blood supply. This is commonly performed after mastectomy for breast cancer treatment.

Showing rates for

National Average

Base Medicare rate

$2,113.52

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

33.9

PE RVU (NF)

25.24

MP RVU

6.2

Total RVU

65.34

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

NCCI bundling edits

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Billing tips

Verify mastectomy diagnosis codes (C50.x or Z90.1x) are properly documented and linked to establish medical necessity
Impact: Prevents denials worth full $2113.52 payment; mastectomy history is absolute requirement for coverage
Distinguish pedicle TRAM (19368) from free TRAM (19364) in operative notes by explicitly documenting preservation of superior epigastric vessels and muscle pedicle
Impact: Prevents downcoding or denials; codes have similar RVUs but different technical requirements and documentation standards
Document total operative time, blood loss, and any complicating factors (radiation, prior surgery, obesity) to support modifier 22 when applicable
Impact: Can increase reimbursement by $422-$1057 (20-50% above base rate) for unusually complex cases
Submit with place of service 21 (inpatient hospital) or 22 (outpatient hospital) as this is not typically performed in office settings
Impact: Ensures correct facility vs non-facility rate application; both rates are $2113.52 for this code
Bundle pre-operative tissue expander removal (11971) only if performed same session; bill separately if different date
Impact: Prevents $150-300 revenue loss from improper bundling of tissue expander codes
Verify patient meets Women's Health and Cancer Rights Act (WHCRA) requirements for insurance coverage of post-mastectomy reconstruction
Impact: Federal law mandates coverage for most group health plans; citing WHCRA in appeals overturns most medical necessity denials

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Frequently asked questions

What is the Medicare reimbursement rate for CPT code 19368 in 2025?

The 2025 Medicare national average reimbursement for CPT 19368 is $2113.52 for both facility and non-facility settings. This rate is based on 65.34 total RVUs (33.9 work RVU + 25.24 PE RVU + 6.2 MP RVU) multiplied by the 2025 conversion factor of $32.3465.

What is the difference between CPT 19368 and 19364 for breast reconstruction?

CPT 19368 describes a pedicle TRAM flap that maintains blood supply through the superior epigastric vessels and rectus muscle pedicle, while 19364 describes a free TRAM flap where the tissue is completely detached and reconnected using microvascular anastomosis to recipient vessels. The pedicle technique (19368) is generally less complex microsurgically but requires tunneling the pedicle beneath the skin.

Does insurance cover CPT 19368 for breast reconstruction after mastectomy?

Yes, the Women's Health and Cancer Rights Act (WHCRA) of 1998 federally mandates that group health plans covering mastectomy must also cover breast reconstruction, including procedures coded with 19368. This includes reconstruction of the breast on which mastectomy was performed, surgery on the opposite breast for symmetry, and treatment of complications.

How many RVUs is CPT code 19368 worth in 2025?

CPT 19368 has a total of 65.34 RVUs in 2025, consisting of 33.9 work RVUs, 25.24 practice expense RVUs (both facility and non-facility), and 6.2 malpractice RVUs. This high RVU value reflects the complexity and time required for this major reconstructive procedure.

Can CPT 19368 be billed bilaterally with modifier 50?

Yes, modifier 50 can be appended to CPT 19368 when bilateral breast reconstruction with pedicle TRAM flaps is performed during the same operative session. Bilateral reimbursement is typically 150% of the unilateral rate, approximately $3170.28 total under Medicare's 2025 fee schedule.

What documentation is required to bill CPT 19368 without denials?

Required documentation includes: proof of prior mastectomy with appropriate diagnosis codes (C50.x or Z90.1x), clear operative note description of pedicle TRAM technique with superior epigastric pedicle preservation, laterality indication, tissue harvest details, flap inset description, and medical necessity statement. Documentation must distinguish pedicle technique from free flap variants.

What modifiers are commonly used with CPT code 19368?

Common modifiers for 19368 include: modifier 50 (bilateral procedure), RT/LT (laterality), modifier 22 (increased procedural services for complex cases), modifier 58 (staged procedure during global period), modifier 78 (return to OR for complications), and modifier AS (assistant surgeon). Each modifier affects reimbursement differently and requires specific documentation.