Summary & Overview
CPT 19369: Bilateral Lower Abdominal TRAM Flap Breast Reconstruction
CPT code 19369 represents complex autologous breast reconstruction using bilateral lower abdominal transverse rectus abdominis muscle (TRAM) flaps to recreate breast contour after mastectomy or to repair a breast defect. This procedure is a clinically significant option for patients seeking reconstruction with their own tissue, affecting surgical practice patterns, hospital resource use, and payer coverage decisions across the country. Key payers typically involved in coverage and reimbursement discussions include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
Readers will find an overview of clinical context for TRAM flap reconstruction, common sites of service and expected care setting, and the elements that affect billing and service lines for reconstructive breast surgery. The publication summarizes benchmarking insights and policy-relevant considerations that influence coverage determinations and utilization management. Where available, it highlights payer coverage patterns, claim coding considerations, and clinical nuances that drive appropriate use. Data not available in the input will be noted as such elsewhere in the document.
Billing Code Overview
CPT code 19369 describes a surgical breast reconstruction procedure in which the surgeon harvests a flap of skin, fat, and transverse rectus abdominis muscle from both sides of the lower abdomen, creating two vascularized tissue strips that remain attached at their original site and are tunneled or transferred to the chest to recreate the contour of a breast. The technique restores cosmetic appearance following mastectomy or to repair a breast defect.
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Service type: Complex autologous breast reconstruction using bilateral lower abdominal TRAM flap harvest and transfer
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Typical site of service: Inpatient or ambulatory surgical center setting for major reconstructive surgery
Clinical & Coding Specifications
Clinical Context
A typical patient is a woman who has undergone unilateral or bilateral mastectomy for breast cancer and presents for immediate or delayed autologous breast reconstruction using a bilateral pedicled transverse rectus abdominis myocutaneous flap. The surgical workflow includes preoperative imaging and clearance, marking of abdominal donor sites, harvesting of bilateral lower abdominal skin, fat, and portions of the rectus abdominis muscle while preserving vascular pedicles, tunneling or transposing the flaps to the chest, insetting and suturing the flaps to create breast mound contour, and closure of abdominal donor sites. Perioperative care includes general anesthesia, intraoperative monitoring of flap perfusion, drains placement, and postoperative monitoring in a recovery unit or inpatient surgical ward with instructions for wound care and follow-up with plastic surgery for flap viability and aesthetic outcomes.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier — standard reporting | Used when no special modifier applies to the service. |
| 11 | Office or outpatient evaluation and management default — CMS use varies | Applied when the service is carried out in the usual setting without unusual circumstances (rare for surgical reporting; limited CMS use).
| 22 | Increased procedural services | Use when the procedure required substantially greater work than typical due to complexity, extensive dissection, or prolonged operative time.
| 23 | Unusual anesthesia | Use when general anesthesia was contraindicated and an unusual anesthesia technique was required for medically complex patients.
| 26 | Professional component | Use if reporting only the surgeon’s professional component separate from technical components billed by facility (rare for this global surgical code).
| 50 | Bilateral procedure | Use when billing for bilateral breast reconstructions to indicate both sides were treated if payer requires a bilateral modifier in addition to bilateral-specific rules.
| 51 | Multiple procedures | Use when another procedure is performed in the same operative session and payer requires identification of multiple procedures.
| 52 | Reduced services | Use when the procedure was partially reduced or not completed as planned.
| 62 | Two surgeons | Use when two surgeons of different specialties work together as co-surgeons on technically demanding aspects of the reconstruction.
| 63 | Procedure performed on infants less than 4 kg — pediatric use | Rarely applicable; include only when patient meets weight criteria.
| 66 | Surgical team | Use when a surgical team approach is documented for complex reconstruction requiring multiple surgeons performing distinct critical portions.
| 78 | Unplanned return to operating room for related procedure during postoperative period | Use if the patient required an immediate reoperation for flap compromise or other complication related to the initial reconstruction.
| 80 | Assistant surgeon | Use when an assistant surgeon provides assistance and billing requires designation.
| 81 | Minimum assistant surgeon | Use when a minimal level of assistance was provided and payer recognizes this modifier.
| 82 | Assistant surgeon when qualified resident surgeon not available | Use when an assistant surgeon is used because a qualified resident was not available.
| Taxonomy Code | Specialty | Notes |
|---|---|---|
| 208100000X | Plastic Surgery | Primary specialty performing autologous breast reconstruction using TRAM flaps. |
| 208D00000X | General Surgery | General surgeons with reconstructive expertise or in oncologic contexts may participate in mastectomy and immediate reconstruction.
| 207P00000X | Surgical Oncology | Surgical oncologists coordinate cancer extirpation and may collaborate with plastic surgeons for immediate reconstruction.
| 207K00000X | Obstetrics & Gynecology | Gynecologic-oncology or gynecologic surgeons rarely involved when reconstructive needs overlap with abdominal procedures.
| 225400000X | Anesthesiology | Provides intraoperative anesthetic management and perioperative pain control, relevant to complex reconstructive cases.
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
C50.911 | Malignant neoplasm of unspecified site of right female breast | Indicates breast cancer requiring mastectomy and subsequent reconstruction. |
| C50.912 | Malignant neoplasm of unspecified site of left female breast | Indicates breast cancer on the left requiring mastectomy and reconstruction.
| Z90.10 | Acquired absence of unspecified breast(s) | Used for patients with prior mastectomy seeking reconstruction.
| Z42.1 | Encounter for breast reconstruction following mastectomy | Directly maps to the clinical intent for reconstruction procedures.
| T81.89XA | Other complications of procedures, initial encounter | Used when documenting postoperative complications such as flap compromise or wound issues requiring intervention.
| N64.89 | Other specified disorders of breast | May be used for nonmalignant indications leading to reconstruction or corrective surgery.
| Z85.3 | Personal history of malignant neoplasm of breast | Indicates prior breast cancer history relevant to reconstructive planning.
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
19342 | Immediate or delayed insertion of breast prosthesis following mastopexy, mastectomy, or in reconstruction | May be used for implant-based reconstruction when implants are chosen instead of or in combination with autologous flaps. |
| 19357 | Tissue expander placement in breast reconstruction | Performed when staged reconstruction uses tissue expanders prior to implant exchange; may occur before or instead of TRAM flap reconstruction.
| 19350 | Nipple-areola reconstruction | Often performed as a secondary or concurrent procedure to restore nipple-areola complex after reconstruction.
| 49560 | Repair of incisional or ventral hernia with mesh | Relevant when abdominal donor site complications (hernias) require repair during the same hospitalization or as a subsequent procedure.
| 15734 | Muscle, myocutaneous, or fasciocutaneous free flap with microvascular anastomosis (trunk) | Used when reconstruction is performed as a free flap (e.g., free TRAM or DIEP) requiring microvascular anastomosis instead of pedicled bilateral TRAM technique.
| 11042 | Debridement; skin, subcutaneous tissue and muscle | May be used if significant debridement of abdominal donor or chest site is necessary for infection or necrosis related to the reconstruction.