Summary & Overview
CPT 19361: Breast Reconstruction with Latissimus Dorsi Flap, No Implant
CPT code 19361 represents breast reconstruction using a latissimus dorsi flap without the use of a prosthetic implant. This surgical procedure is a critical option for patients undergoing mastectomy, providing a natural tissue reconstruction alternative. Nationally, this code is significant in the context of cancer care and reconstructive surgery, as it addresses both clinical and quality-of-life outcomes for patients affected by breast cancer and related conditions.
Major payers covering this procedure include Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare. The publication offers insights into payer coverage, clinical benchmarks, and policy updates relevant to this code. Readers will gain an understanding of the procedure's clinical context, typical site of service, and its role within the broader landscape of breast reconstruction options. The analysis also highlights associated diagnoses, related CPT codes, and common billing modifiers, providing a comprehensive overview for stakeholders in healthcare policy, billing, and clinical practice.
This summary serves as a resource for understanding the national importance of CPT code 19361, including payer coverage and procedural benchmarks, without referencing state-specific data. It is intended for professionals seeking clarity on coding, reimbursement, and clinical application in breast reconstruction surgery.
CPT Code Overview
CPT code 19361 describes breast reconstruction with latissimus dorsi flap, without prosthetic implant. This procedure is a form of plastic and reconstructive surgery typically performed in an inpatient hospital setting. It involves using the latissimus dorsi muscle and overlying skin from the back to reconstruct the breast, often following mastectomy due to cancer or other conditions. The absence of a prosthetic implant distinguishes this approach from other reconstruction methods, offering patients a natural tissue option for breast restoration.
Clinical & Coding Specifications
Clinical Context
A typical patient scenario involves an individual who has undergone a mastectomy due to breast cancer or another malignant neoplasm affecting the breast. The patient is admitted to an inpatient hospital setting for breast reconstruction using a latissimus dorsi muscle flap, without the placement of a prosthetic implant. The procedure is performed by a plastic and reconstructive surgeon, sometimes in collaboration with a surgical oncologist, to restore the breast's contour and appearance following cancer treatment. The clinical workflow includes preoperative assessment, surgical planning, intraoperative harvesting and transfer of the latissimus dorsi flap, and postoperative care to monitor for complications and ensure optimal healing.
Coding Specifications
-
Modifier
51(Multiple Procedures): Used when more than one procedure is performed during the same operative session. This modifier indicates that the procedure is part of a group of multiple procedures. -
Modifier
62(Two Surgeons): Applied when two surgeons are required to perform distinct parts of the procedure, each acting as a primary surgeon.
| Modifier Code | Description |
|---|---|
51 | Multiple Procedures |
62 | Two Surgeons |
- Provider Taxonomies:
| Taxonomy Code | Specialty Name |
|---|---|
208200000X | Plastic and Reconstructive Surgery |
2086S0122X | Surgical Oncology |
208600000X | Surgery |
These taxonomies represent the specialties most commonly involved in breast reconstruction procedures.
Related Diagnoses
-
C44.511- Basal cell carcinoma of skin of breast- Indicates a malignant lesion requiring excision and possible reconstruction.
-
C44.521- Squamous cell carcinoma of skin of breast- Represents a skin cancer diagnosis necessitating surgical removal and reconstruction.
-
C44.591- Other specified malignant neoplasm of skin of breast- Covers other malignant neoplasms affecting breast skin, relevant for reconstructive surgery.
-
C50.011- Malignant neoplasm of nipple and areola, right female breast- Cancer involving the nipple/areola, often leading to mastectomy and reconstruction.
-
C50.012- Malignant neoplasm of nipple and areola, left female breast- Similar to above, but affecting the left breast.
-
C50.021- Malignant neoplasm of nipple and areola, right male breast- Indicates cancer in the nipple/areola of the right male breast, requiring surgical intervention.
-
C50.022- Malignant neoplasm of nipple and areola, left male breast- Cancer in the left male breast, relevant for reconstructive procedures.
-
C50.111- Malignant neoplasm of central portion of right female breast- Central breast cancer, often resulting in mastectomy and need for reconstruction.
-
C50.112- Malignant neoplasm of central portion of left female breast- Central cancer in the left breast, leading to reconstructive surgery.
-
C50.121- Malignant neoplasm of central portion of right male breast- Central cancer in the right male breast, relevant for reconstruction.
-
C50.122- Malignant neoplasm of central portion of left male breast- Central cancer in the left male breast, requiring reconstructive intervention.
-
C50.211- Malignant neoplasm of upper-inner quadrant of right female breast- Cancer in the upper-inner quadrant, often necessitating mastectomy and reconstruction.
-
C50.212- Malignant neoplasm of upper-inner quadrant of left female breast- Cancer in the upper-inner quadrant of the left breast, relevant for reconstructive surgery.
Each diagnosis represents a clinical scenario where breast reconstruction with a latissimus dorsi flap may be indicated following surgical removal of malignant tissue.
Related CPT Codes
-
19364- Breast reconstruction with free flap- Used for breast reconstruction utilizing a free tissue transfer, as an alternative to the latissimus dorsi flap. May be selected based on patient anatomy or preference.
-
19367- Breast reconstruction, single pedicled TRAM flap- Involves reconstruction using a single pedicled transverse rectus abdominis myocutaneous (TRAM) flap. This is another autologous tissue option.
-
19368- Breast reconstruction, one pedicled TRAM flap with anastomosis- Similar to
19367, but includes microvascular anastomosis for improved blood supply.
- Similar to
-
19369- Breast reconstruction, bipedicled TRAM flap- Utilizes a bipedicled TRAM flap for reconstruction, often for larger defects or when additional tissue is needed.
These codes are related as alternative methods for breast reconstruction following mastectomy. They may be used instead of or in conjunction with 19361, depending on clinical circumstances and patient needs.
National Reimbursement Benchmarks
For CPT code 19361, national mean rates show that Medicare reimburses at $1,404.85, while the average commercial payer (BUCA) is higher at $1,952.40. Among individual commercial payers, UnitedHealth Group and Cigna have the highest mean rates, at $2,678.73 and $2,526.20 respectively, while Aetna is the lowest at $1,238.82.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Medicare has the tightest range ($100.00), indicating less variability in rates. In contrast, UnitedHealth Group and Cigna exhibit the widest dispersions, with ranges of $1,614.11 and $1,470.00 respectively, reflecting greater variability in commercial reimbursement.
The table and chart below present a full breakdown of national benchmarks for each payer, including mean rates and percentile values.
State Benchmarks
State: AK1 / 50
Alaska Benchmarks
Alaska exhibits a substantial spread in reimbursement rates for CPT code 19361 across payers, with UnitedHealth Group and Blue Cross Blue Shield offering the highest mean rates. The rate spread, calculated as the difference between the 75th and 25th percentiles, is most pronounced for UnitedHealth Group ($279.20) and Blue Cross Blue Shield ($1,328.00), indicating significant variability in commercial payer reimbursements. Medicare's spread is much narrower at $122.00, reflecting more consistent rates.
Compared to national averages, Alaska's commercial payers consistently reimburse at much higher levels, with Blue Cross Blue Shield and UnitedHealth Group showing the largest deviations from their national mean rates. The table and chart below present the full breakdown of payer-specific rates in Alaska, highlighting the state's unique reimbursement landscape for this procedure.
Key Insights for Alaska
- UnitedHealth Group is the highest paying payer in Alaska for CPT 19361, with a mean rate of $4,606.38.
- Medicare is the lowest paying payer in Alaska, with a mean rate of $1,381.54.
- All commercial payers in Alaska reimburse at significantly higher rates than their respective national averages, with Blue Cross Blue Shield and UnitedHealth Group showing the largest deviations.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.