Brst rcnstj 2 pdcl tram flap

CPT code 19369 covers breast reconstruction using a bilateral pedicle TRAM flap procedure, where tissue from the lower abdomen is used to reconstruct both breasts while maintaining its original blood supply connection.

Showing rates for

National Average

Base Medicare rate

$1,964.08

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

31.31

PE RVU (NF)

23.68

MP RVU

5.73

Total RVU

60.72

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

NCCI bundling edits

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Billing tips

Document total operative time and compare to published mean operative times for this procedure (typically 6-8 hours) to support modifier 22 consideration when significantly exceeded
Impact: Potential 20-30% reimbursement increase ($392-589 additional) when operative time exceeds 10-12 hours with proper documentation
Never append modifier 50 to CPT 19369 as the code descriptor specifically indicates bilateral procedure; doing so will trigger automatic denial for duplicate billing
Impact: Prevents denial and subsequent appeals process that delays payment by 30-90 days
Separately bill for tissue expander removal (11971) if performed during delayed reconstruction, but verify medical necessity documentation links to previous tissue expansion
Impact: Additional $150-300 reimbursement when appropriately documented and not considered incidental
Obtain pre-authorization demonstrating medical necessity for bilateral reconstruction, including photographs, cancer diagnosis codes, and genetic testing results for BRCA mutations when applicable
Impact: Reduces denial rate from approximately 15-25% to under 5% for bilateral procedures
Bill assistant surgeon services separately using modifier 80 or AS (depending on credential) when assistant surgeon participation exceeds 2 hours and is medically necessary
Impact: Captures 16-20% of allowed amount ($314-393) for qualified assistant surgeon services
Coordinate billing with facility for implant/mesh placement if used for abdominal wall closure; ensure CPT 15777 for implantable biological mesh is not bundled into facility claim

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Frequently asked questions

What is the Medicare reimbursement rate for CPT code 19369 in 2025?

The 2025 Medicare national average reimbursement for CPT 19369 is $1,964.08 for both facility and non-facility settings. This rate is based on 60.72 total RVUs (31.31 work RVUs, 23.68 practice expense RVUs, and 5.73 malpractice RVUs) multiplied by the 2025 conversion factor of 32.3465.

Does CPT 19369 require modifier 50 for bilateral breast reconstruction?

No, CPT 19369 should NOT have modifier 50 appended because the code descriptor specifically indicates bilateral procedure ("Brst rcnstj 2 pdcl tram flap" - reconstruction of 2 breasts). Adding modifier 50 will result in claim denial for duplicate billing.

Can CPT 19369 be billed with bilateral mastectomy codes on the same date of service?

Yes, CPT 19369 can be billed with bilateral mastectomy codes (19303-19307) when immediate reconstruction is performed, but requires careful documentation of medical necessity and may require modifier 59 or separate operative reports to prevent bundling denials. Many payers require pre-authorization for same-day mastectomy and reconstruction.

What is the global period for CPT code 19369?

CPT 19369 has a 090-day global surgical period, meaning all routine postoperative care for 90 days following surgery is included in the reimbursement. Any complications requiring return to OR may be separately billable with modifier 78, while unrelated procedures require modifier 79.

How do I bill for assistant surgeon services with CPT 19369?

Assistant surgeon services for CPT 19369 should be billed using the same code with modifier 80 (physician assistant), AS (physician assistant, nurse practitioner, or clinical nurse specialist), 81 (minimum assistant surgeon), or 82 (when qualified resident unavailable). Reimbursement is typically 16-20% of the allowed amount, or approximately $314-393 for Medicare.

What diagnosis codes support medical necessity for CPT 19369?

Common supporting diagnosis codes include Z90.1- (acquired absence of breast), C50.- (malignant neoplasm of breast), Z85.3 (personal history of malignant neoplasm of breast), Z15.01 (genetic susceptibility to breast cancer - BRCA), and Z80.3 (family history of breast malignancy). Documentation must clearly link diagnosis to bilateral reconstruction necessity.

What are the most common reasons for CPT 19369 claim denials?

The most common denials include: incorrect use of modifier 50 causing duplicate billing flags, medical necessity denials for cosmetic determination (especially prophylactic bilateral cases without genetic documentation), bundling with same-day mastectomy codes, and insufficient operative report documentation of pedicle technique and bilateral nature of reconstruction.