Summary & Overview
CPT 19368: TRAM Flap Breast Reconstruction with Microvascular Anastomosis
CPT code 19368 represents microsurgical breast reconstruction using a transverse rectus abdominis myocutaneous (TRAM) flap with vascular anastomosis. This complex reconstructive procedure restores breast contour after mastectomy or repairs post-surgical defects and is an important modality in breast cancer care and reconstructive surgery nationally. It carries implications for surgical capacity, perioperative resources, and coverage policy because it requires microvascular expertise and specialized facility resources.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise review of the clinical context for CPT code 19368, typical sites of service, common billing modifiers used with complex reconstructive procedures, and the payer landscape relevant to coverage and authorization practices. The publication summarizes expected service line placement, common clinical indications, and practical coding considerations to support accurate claim submission and administrative planning.
This summary is intended for national audiences including surgical departments, coding and revenue cycle teams, and policy analysts seeking an overview of the clinical and administrative aspects of CPT code 19368. Data not available in the input are noted where applicable.
Billing Code Overview
CPT code 19368 describes surgical breast reconstruction using a transverse rectus abdominis myocutaneous (TRAM) flap with microvascular anastomosis. The procedure harvests a flap of skin, subcutaneous fat, and transverse rectus abdominis muscle from the lower abdomen, preserves a vascularized tissue pedicle, transposes and sculpts the flap to recreate the breast contour, and connects the flap vessels to recipient vessels at the mastectomy site using microvascular technique to restore cosmetic appearance after mastectomy or to repair a post-surgical defect.
Service type: Reconstructive microvascular flap surgery
Typical site of service: Inpatient or outpatient hospital surgical suite with microvascular capability; may occur in ambulatory surgery centers equipped for complex reconstructive procedures
Clinical & Coding Specifications
Clinical Context
A 48-year-old woman with a history of left mastectomy for invasive ductal carcinoma presents for planned autologous breast reconstruction using a pedicled/transverse rectus abdominis myocutaneous (TRAM) flap with microvascular anastomosis to recreate breast contour. Preoperative workup includes oncologic clearance, imaging of the chest and abdomen, and assessment of abdominal vascular anatomy. The surgical team (plastic surgeon and anesthesiologist) evaluates comorbidities such as diabetes and smoking status and obtains informed consent addressing flap risks, donor-site morbidity, and possible need for revision. On the day of surgery the patient receives general anesthesia; the plastic surgeon harvests a lower abdominal flap containing skin, fat, and the transverse rectus abdominis muscle with its vascular pedicle, tunnels or transposes the flap to the mastectomy site, performs microvascular connection of flap vessels to recipient chest vessels, shapes the flap to restore breast contour, and closes donor and recipient sites. Postoperative care includes flap perfusion monitoring, pain control, DVT prophylaxis, wound care, and follow-up visits for assessment of healing and symmetry. Typical site of service is an inpatient hospital operating room or ambulatory surgical center with microsurgical capabilities and an overnight stay for flap monitoring when inpatient care is required. Common clinical indications include reconstruction after mastectomy, repair of post-oncologic defects, or revision of prior reconstructive failure.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
62 | Two surgeons | Use when two surgeons from different specialties work together performing distinct portions of the reconstruction (e.g., microvascular anastomosis by a second attending microsurgeon). |
63 | Procedure performed on infants less than 4 kg | Rarely applicable; use if patient meets weight criteria. |
66 | Surgical team technique | Use when a coordinated surgical team approach is documented for complex reconstructions requiring multiple surgical teams. |
78 | Unplanned return to OR | Use when patient requires immediate return to the operating room for complications related to the flap within the global period. |
79 | (Not in provided list) | Data not available in the input. |
80 | Assistant surgeon | Use when an assistant surgeon performs a portion of the procedure and billing requires reporting (commonly a resident or another attending). |
81 | Minimum assistant surgeon | Use when minimal assistant involvement is documented. |
82 | Assistant surgeon (qualifying circumstances) | Use when a qualified resident without credentialed assistant surgeon is used under qualifying circumstances. |
22 | Increased procedural services | Use when operative complexity or time is substantially greater than typical and well documented. |
52 | Reduced services | Use when the planned reconstruction is partially reduced or not completed as documented. |
53 | Discontinued procedure | Use when the procedure is started but terminated due to extenuating circumstances before completion. |
51 | Multiple procedures | Use when additional distinct procedures are performed during the same operative session (e.g., contralateral breast procedures). |
26 | Professional component | Use when separately reporting only the professional component of a bundled service (rare for this global surgical procedure). |
RT | Right side | Use when procedure is performed on the right breast; append as required by payor. |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
| 208100000X | Plastic Surgery | Primary specialty performing autologous breast reconstruction and microsurgery. |
| 207P00000X | General Surgery | May participate in oncologic resection or combined reconstructive cases. |
| 2080P0206X | Surgical Oncology | In cases combined with tumor resection planning and coordination. |
| 2084P0800X | Thoracic Surgery | Occasionally involved when chest wall or internal mammary vessel exposure is required. |
| 363L00000X | Vascular Surgery | May perform or assist with microvascular anastomosis in complex cases. |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
C50.912 | Malignant neoplasm of unspecified site of right female breast | Breast cancer indication leading to mastectomy and subsequent reconstruction. |
C50.911 | Malignant neoplasm of unspecified site of left female breast | Breast cancer indication leading to mastectomy and subsequent reconstruction. |
Z42.1 | Encounter for breast reconstruction following mastectomy | Specific code denoting encounter for reconstruction after mastectomy. |
Z90.13 | Acquired absence of right breast and nipple | Post-mastectomy status indicating need for reconstruction. |
Z90.11 | Acquired absence of left breast and nipple | Post-mastectomy status indicating need for reconstruction. |
T81.89XA | Other complications of procedures, initial encounter | Used when reporting early postoperative complications such as wound dehiscence or partial flap loss. |
Z85.3 | Personal history of malignant neoplasm of breast | History code often present in reconstructive patients following treatment. |
N18.3 | Chronic kidney disease, stage 3 (example comorbidity) | Represents a common comorbidity that may impact perioperative planning and risk stratification. |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
19318 | Reduction mammoplasty | May be performed simultaneously for symmetry or contralateral balancing during reconstruction. |
19350 | Nipple/areola reconstruction | Common secondary procedure performed after the initial flap reconstruction to restore nipple-areolar complex. |
15734 | Muscle, myocutaneous, or fasciocutaneous flap (trunk) | Descriptor for flap harvest techniques; may be used for portions of donor-site reporting depending on payer bundling. |
97607 | Negative pressure wound therapy (wound VAC) | May be used postoperatively for donor-site or chest wound management when indicated. |
36415 | Collection of venous blood by venipuncture | Routine perioperative labs; often performed pre- and postoperatively for monitoring. |
20926 | Muscle or myocutaneous free flap with microvascular anastomosis (muscle or myocutaneous) | Alternate coding for free flap reconstruction in some payer contexts and for related muscle-based free flap procedures. |