CPT 19364 Breast Reconstruction Reimbursement | OpenPayer

Summary & Overview

CPT 19364: Breast Reconstruction with Free Flap

CPT code 19364 represents breast reconstruction with free flap, a highly specialized surgical procedure used to restore breast shape and function following mastectomy or other breast surgeries. This code is central to the field of plastic and reconstructive surgery, reflecting advanced techniques that improve patient outcomes and quality of life. The procedure is most commonly performed in hospital inpatient or outpatient settings, underscoring its complexity and the need for specialized surgical teams.

Nationally, breast reconstruction with free flap is covered by major payers including Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare. Coverage policies and reimbursement benchmarks for this procedure are critical for providers, hospitals, and patients navigating post-mastectomy care. Readers will gain insight into payer coverage, clinical context, and policy updates relevant to this CPT code. The publication also addresses common billing modifiers, associated clinical taxonomies, and ICD-10 diagnoses linked to breast cancer and related conditions. Understanding these elements is essential for accurate coding, compliance, and optimizing patient access to reconstructive surgery.

This summary provides a comprehensive overview of CPT code 19364, highlighting its clinical significance, payer landscape, and key considerations for stakeholders in the healthcare system.

AetnaBlue Cross Blue ShieldCigna HealthMedicareUnitedHealthcareCPT 19364breast reconstructionfree flapplastic surgeryreconstructive surgeryhospital inpatienthospital outpatientsurgical oncologymedical billingclinical coding

CPT Code Overview

CPT code 19364 describes breast reconstruction with free flap, a complex surgical procedure performed by plastic and reconstructive surgeons. This service is typically provided in a hospital inpatient or outpatient surgical setting, such as place of service 21 or 24. The procedure involves the transfer of tissue from another part of the patient's body to reconstruct the breast, often following mastectomy due to cancer or other medical conditions. Breast reconstruction with free flap is a key option for patients seeking restoration of breast shape and appearance after surgical removal.

Clinical & Coding Specifications

Clinical Context

A typical patient scenario involves a female patient diagnosed with a malignant neoplasm of the breast, such as basal cell carcinoma, squamous cell carcinoma, or cancer of the nipple and areola. Following a mastectomy or excision of the tumor, the patient undergoes breast reconstruction with a free flap. This procedure is performed by a plastic or reconstructive surgeon in a hospital inpatient or outpatient surgical setting. The clinical workflow includes preoperative assessment, surgical planning, excision of the tumor, and immediate or delayed reconstruction using autologous tissue transferred as a free flap to restore breast contour and function.

Coding Specifications

Modifier 51: Indicates multiple procedures were performed during the same operative session. Used when breast reconstruction with free flap (19364) is performed alongside other surgical procedures.
Modifier 59: Denotes a distinct procedural service. Applied when breast reconstruction with free flap (19364) is performed separately from other procedures that are not typically reported together.

Provider Taxonomy Code	Specialty Name

National Reimbursement Benchmarks

For CPT code 19364, national mean rates show that Medicare reimburses at $2,402.95, while the average commercial benchmark (BUCA) is higher at $3,599.10. Commercial payers such as UnitedHealth Group and Cigna have the highest mean rates, with UnitedHealth Group at $4,825.82 and Cigna at $4,641.75.

Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Medicare exhibits the tightest range ($170.00), indicating relatively consistent rates nationwide. In contrast, UnitedHealth Group and Cigna display the widest dispersions, with ranges of $2,787.00 and $2,707.00 respectively, reflecting greater variability in commercial reimbursement.

The table and chart below present a detailed breakdown of national benchmarks for each payer, including mean rates and percentile values.

State Benchmarks

State: Alaska1 / 50

Alaska Benchmarks

Alaska exhibits a substantial spread in reimbursement rates for CPT code 19364, with the highest commercial payer (Aetna) showing no variability between percentiles, while Blue Cross Blue Shield and Cigna display notable differences between their 25th and 75th percentiles. For example, Cigna's rate spread is $3,754.45 ($7,037.45 minus $3,283.00), and Blue Cross Blue Shield's is $2,311.17 ($7,329.00 minus $5,017.83), indicating a range of negotiated rates across providers. In contrast, Aetna's rates are uniform at $13,294.00 across all percentiles.

Compared to national averages, Alaska's commercial payers consistently reimburse at much higher rates, with Aetna's mean rate in Alaska nearly five times its national mean. Medicare rates in Alaska are closely aligned with national benchmarks, showing minimal deviation. The table and chart below present the full breakdown of payer-specific rates in Alaska for CPT code 19364.

Key Insights for Alaska

Aetna is the highest paying payer in Alaska for CPT 19364, with a mean rate of $11,576.71, while Medicare is the lowest at $2,368.30.
All commercial payers in Alaska reimburse at rates significantly above their respective national averages, with Aetna's mean rate nearly five times higher than its national benchmark.
The rate spread is widest for Aetna ($0, as all percentiles are equal), while Blue Cross Blue Shield and Cigna show more variability, indicating less uniformity in negotiated rates.

CPT 19370: Surgical Release of Breast Implant Capsule

19357-TISSUE-EXPANDER-PLACEMENT-BREAST

CPT 19357: Tissue Expander Placement for Breast Reconstruction

CPT-19355-INVERTED-NIPPLE-CORRECTION

CPT 19355: Correction of Inverted Nipple

CPT-19369-BILATERAL-LOWER-ABDOMEN-TRAM-FLAP-BREAST-RECONSTRUCTION

CPT 19369: Bilateral Lower Abdominal TRAM Flap Breast Reconstruction

CPT-19371-BREAST-IMPLANT-CAPSULE-RELEASE-INTRACAPSULAR-REMOVAL

CPT 19371: Breast Implant Capsule Release with Intracapsular Removal

CPT-19342-BREAST-IMPLANT-INSERTION-OR-REPLACEMENT-POST-MASTECTOMY

CPT 19342: Breast Implant Insertion or Replacement After Mastectomy

CPT-19328-BREAST-IMPLANT-REMOVAL-EXPLANTATION

CPT 19328: Removal of Previously Placed Breast Implant

CPT-19330-BREAST-IMPLANT-EXPLANTATION-RUPTURE

CPT 19330: Removal of Ruptured Breast Implant Material

CPT-19380-BREAST-REVISION-SURGICAL-COSMETIC-CORRECTION

CPT 19380: Breast Revision for Cosmetic or Complication Correction

19318-REDUCTION

CPT 19318: Reduction Mammoplasty

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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.