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Last Updated: August 6, 2026
Key takeaways
CPT code 19367 covers breast reconstruction with a single-pedicle TRAM flap, including closure of the donor site.
Laterality modifiers RT and LT are required on every unilateral claim, and modifier -62 applies when two surgeons operate together.
Code 19368 adds a microvascular anastomosis to a single pedicle, while 19369 is the bipedicled TRAM flap.
Medicare covers 19367 as medically necessary after mastectomy, and the Women’s Health and Cancer Rights Act mandates group health plan coverage.
Practice management software like Pabau tracks prior authorizations and modifier rules, so fewer 19367 claims come back denied.
CPT code 19367 covers breast reconstruction with a transverse rectus abdominis myocutaneous (TRAM) flap, single pedicle, including closure of the donor site. It applies after mastectomy, when abdominal skin, fat, and one rectus abdominis muscle are moved to rebuild the breast mound.
This guide covers everything a biller needs for a clean 19367 claim. That means the descriptor, modifiers, Medicare reimbursement, and ICD-10 pairings. It also covers coverage rules, documentation standards, the anesthesia crosswalk, and the neighboring codes people confuse it with.
Reconstructive practices that keep charting and billing in one system catch most of these problems earlier. Purpose-built plastic surgery EMR software ties the operative note to the claim, so nobody re-keys clinical detail into a billing screen.
CPT code 19367: Definition and procedure description
CPT code 19367 applies when a surgeon rebuilds the breast with a TRAM flap on a single pedicle. The American Medical Association maintains the CPT code set. It defines the procedure as the harvest and transfer of abdominal skin, fat, and rectus abdominis muscle.
That tissue travels on one vascular pedicle to form the breast mound. Donor site closure is included in the code and is never billed separately.
The single-pedicle designation drives code selection. CPT code 19367 requires one vascular pedicle connecting the flap to the abdominal blood supply. If the surgeon adds a microvascular anastomosis to improve perfusion of that single pedicle, the claim moves to 19368.
Coders and surgeons usually call this supercharging, and other microvascular transfers such as CPT code 20957 use the same anastomosis technique. When both rectus abdominis muscles carry the flap, the bipedicled procedure is coded 19369. Billing 19367 for either variant is a coding error that payers routinely catch on audit.
Modifiers and laterality rules
Modifier selection is one of the most common sources of denial on this claim. Most payers require a laterality modifier. Co-surgery and assistant surgeon modifiers have to match the operative arrangement described in the record.
Medicare requires laterality modifiers on all unilateral procedures. A 19367 claim submitted without RT or LT will be rejected by most Medicare Administrative Contractors (MACs). The AAPC’s CPT code reference carries further modifier guidance and the bundling edits for this code family.
Reimbursement and RVUs for CPT code 19367
Medicare pays for this procedure using the Resource-Based Relative Value Scale (RBRVS). The CMS Physician Fee Schedule publishes updated rates each January.
The figures below are national averages. Check them against the current-year schedule and your own locality adjustment before you quote a number.
CPT code 19367 is a major surgical procedure, so the 90-day global period applies. Anything rendered inside that window is bundled into the primary payment. An unrelated E&M visit is payable only when a separate diagnosis supports it.
Pro Tip
Run the locality adjustment before you quote an expected payment. A practice in San Francisco sits well above the national geographic practice cost index, while rural practices often sit below it. The CMS Physician Fee Schedule lookup filters by MAC jurisdiction and state, which gives you the rate your contract will actually pay.
ICD-10 codes that support the claim
Medical necessity has to be supported by a paired ICD-10-CM diagnosis code. Most claims combine a reconstruction encounter code with an underlying history or active breast malignancy code. The table below lists the diagnoses paired most often.
Sequence Z42.3 as the principal diagnosis when the patient presents solely for reconstruction, and add Z85.3 to establish the underlying cancer history. When mastectomy and reconstruction happen in the same operative session, the malignancy code takes principal position.
The mastectomy itself is billed separately under a code such as CPT code 19305. Verify every diagnosis code against the current fiscal year tabular list, since CMS updates them annually.
Coverage policy and medical necessity
Federal law mandates coverage of this procedure under most group health plans. The Women’s Health and Cancer Rights Act (WHCRA) of 1998 requires any plan that covers mastectomy to also cover the reconstruction. That includes reconstruction of the other breast for symmetry, prostheses, and treatment of physical complications.
WHCRA reaches group health plans and group health insurance issuers. It does not reach every individual market plan, short-term plan, or grandfathered plan. Confirm the plan type before you assume the reconstruction is covered.
- Medicare: Covers post-mastectomy reconstruction as medically necessary per CMS article A56587. Coverage requires documented malignancy, or a prophylactic mastectomy in a BRCA carrier. Prior authorization rules vary by MAC.
- Medicaid: Coverage varies by state. Most states follow federal WHCRA requirements for Medicaid managed care plans, but fee-for-service Medicaid coverage has to be verified state by state.
- Commercial payers: Most follow WHCRA. Individual plan criteria for timing, surgeon qualifications, and preauthorization differ between BCBS, Aetna, UnitedHealth, and regional plans.
- Prior authorization: Almost universally required. Obtain authorization before scheduling, then record the authorization number in the billing record and on the claim.
An expired authorization is the quietest way to lose payment on a case this size. Practices running plastic surgery practice management at scale attach authorization status to the booking. The surgery date and the authorization window then sit side by side.
Documentation requirements for the operative report
Payer audits on this code focus almost entirely on the operative report. A claim with no laterality statement, no mention of pedicle type, or no donor site closure notes will not survive retrospective review. The report needs every element below.
- Diagnosis and indication: Documented history of mastectomy, or a concurrent mastectomy. Malignancy or genetic risk must be confirmed in the medical record.
- Laterality: An explicit statement of right or left breast reconstruction. This supports the RT or LT modifier and heads off laterality denials.
- Pedicle type: The note must state “single pedicle” to separate 19367 from 19369, the bipedicled code, and from 19368, the supercharged variant.
- Donor site work: Describe the harvest, including the abdominal incision, muscle dissection, and closure technique. Donor site closure is included in 19367 and never appears as a separate line item.
- Medical necessity statement: A letter of medical necessity, or a pre-operative evaluation note explaining why reconstruction is appropriate for this patient.
- Prior authorization reference: The authorization number obtained from the payer before surgery.
Multi-surgeon cases need one more line: who performed which component. That sentence is what supports modifier -62 when the payer asks. Digital forms and structured operative note templates keep these elements from slipping at the moment of dictation.
Reconstruction records rarely start in one place. The mastectomy date and pathology report often sit with the oncology or women’s health team.
Practices using OBGYN EMR software should share that history before the claim goes out. Oncology records are sensitive, so keep HIPAA-compliant workflows in place whenever they move between systems.
Anesthesia code for TRAM flap reconstruction
The anesthesia code that pairs with 19367 is 00402, which covers anesthesia for reconstructive procedures on the breast. Radical and modified radical breast procedures map to CPT code 00404 instead. The anesthesiologist bills this separately from the surgical claim.
Base units for 00402 are typically five, with time units added in 15-minute increments under the standard anesthesia formula.
Verify base units and modifier requirements against current ASA crosswalk data. Anesthesia modifiers such as QZ, AA, QK, and QX are payer-specific, so confirm the pairing with your anesthesia department before you submit split claims.
Related CPT codes for breast reconstruction
CPT code 19367 sits in a family of breast reconstruction codes, and picking the wrong member is a frequent, auditable error. The table below sets out what separates each one.
Two of these come up most often alongside 19367. CPT code 19357 covers tissue expander placement when reconstruction is staged, and CPT code 19342 covers the prosthesis insertion that follows. Confirm which diagnosis codes support each one before submission, because LCD and NCD policies differ by payer.
Common billing errors and denial reasons
Denials on this code cluster around a short list of causes. Every one of them is catchable with a review before the claim leaves the practice.
- Missing laterality modifier: A 19367 claim without RT or LT triggers an automatic rejection at most MACs. Append the laterality modifier every time.
- Wrong pedicle code: Billing 19367 when the operative report describes a bipedicled or supercharged flap. Payers routinely request the operative report on these claims.
- Separate donor site billing: Adding a wound repair code such as CPT code 12036 or CPT code 13100 alongside 19367. Donor site closure is bundled and will deny as part of the global service.
- Missing or expired prior authorization: Submitting before authorization is obtained, or after it has lapsed. Record the authorization number on every claim line.
- Insufficient operative note: Notes that describe the outcome but omit the technique. Without the pedicle type, harvest details, and closure steps, the claim cannot withstand a records request.
- Wrong ICD-10 sequencing: Placing the malignancy code first when the patient presents only for a planned reconstruction visit. Z42.3 belongs in principal position there.
Most of these are pattern errors rather than one-off mistakes, which is why they respond well to automation. Plastic surgery billing software with modifier logic and authorization tracking stops the same three or four denials repeating every month.
Pro Tip
Build a five-point pre-submission check for every 19367 claim. Confirm that RT or LT is present. Confirm the operative note says single pedicle. Confirm no separate donor site closure code is attached. Confirm the authorization number is on file. Confirm the ICD-10 sequence matches the encounter type. Running this before submission is the cheapest way to cut TRAM flap denials.
How practice management software simplifies TRAM flap billing
TRAM flap reconstruction is one of the most documentation-heavy procedures in surgical billing. A single claim ties together a high-value code, a mandatory modifier, and ICD-10 sequencing logic.
It also depends on a 90-day global period and an authorization that is still valid. Miss one layer and the practice absorbs a denial plus a resubmission cycle.
Practice management software like Pabau brings those layers into one workflow. You can attach 19367 to a procedure type and set the RT and LT prompts that have to be answered. The claim then links straight to the operative note in the clinical record.
Authorization status shows up in the scheduling and billing views, so staff confirm it before the surgery date instead of discovering a lapse at submission.
Pabau’s claims management software then handles transmission and tracking. Every claim carries the same checks, which is what turns a five-point manual review into something the system does on its own.
High-volume reconstructive schedules benefit most from the checks running automatically. Automated billing workflows flag a missing modifier or an unsupported diagnosis code before transmission. That cuts the manual review your billing team does by hand.
Cut denials on complex reconstructive claims
Pabau helps reconstructive practices track prior authorizations, prompt for the right modifiers, and link operative notes straight to the claim. See how it fits your billing workflow.
Conclusion
Getting 19367 right is a sequencing problem more than a coding one. Pedicle type, laterality, authorization, and ICD-10 order all have to be settled before the surgeon dictates. None of them can be fixed cleanly once the note is signed.
Practices that treat 19367 as a pre-operative checklist rather than a post-operative coding task field far fewer records requests. The shift costs nothing beyond the discipline of confirming five things before surgery day, and it protects a claim worth roughly 34 work RVUs.
Book a demo to see how Pabau connects operative notes, authorizations, and modifier rules for reconstructive surgery billing.
Continue your research
Monitoring flap perfusion after transfer? CPT code 15860 explains how to bill the dye injection used to test vascular flow in a flap.
Billing a free tissue transfer instead? CPT code 20970 covers the free osteocutaneous flap, including its own donor site rules.
Documenting a major donor site harvest? CPT code 20902 walks through the harvest detail payers expect on a large bone graft claim.
Coding a post-surgical tissue complication? ICD-10 code T86.828 covers the other complications of a skin graft and when to reach for it.
Billing breast brachytherapy alongside surgery? CPT code 19297 sets out the modifiers and documentation for device placement.
Frequently asked questions
What is CPT code 19367?
CPT code 19367 is the surgical code for single-pedicle TRAM flap breast reconstruction, including closure of the donor site. TRAM stands for transverse rectus abdominis myocutaneous. It applies to post-mastectomy reconstruction where abdominal tissue is harvested on one vascular pedicle to recreate the breast mound.
What modifiers can be used with CPT code 19367?
RT and LT are the modifiers required most often, because most payers including Medicare want laterality on the claim. Modifier -62 applies when two co-primary surgeons each perform distinct parts of the procedure. Modifier -80 covers an assistant surgeon. Modifier -22 fits an unusually complex reconstruction, supported by detailed operative documentation.
How much does Medicare reimburse for CPT code 19367?
Payment is based on the current-year CMS Physician Fee Schedule and varies by geographic locality. The work RVU is approximately 34.0, which reflects the complexity of major flap reconstruction. Check the national and locality-adjusted rate in the CMS Physician Fee Schedule lookup, since rates are updated each January.
Is CPT code 19367 covered under the Women’s Health and Cancer Rights Act?
Yes, it is generally covered under the Women’s Health and Cancer Rights Act (WHCRA) for group health plans that cover mastectomy. Those plans must also cover reconstruction of the affected breast, reconstruction of the other breast for symmetry, and treatment of complications. WHCRA does not automatically extend to individual market plans, short-term plans, or grandfathered plans, so verify the plan type.
What is the difference between CPT 19367 and CPT 19368?
Both describe a single-pedicle TRAM flap. CPT 19368 is used when the surgeon adds a separate microvascular anastomosis to that single pedicle, a technique known as supercharging. Coders often assume 19368 covers the double pedicle. A bipedicled TRAM flap is coded 19369 instead, and it carries the highest work RVU of the three.
What documentation is required to bill CPT code 19367?
The operative report must record the indication for reconstruction, laterality, confirmation of single-pedicle technique, a description of flap harvest and transfer, and donor site closure. Most payers also want a prior authorization number and a letter of medical necessity. A missing element here is one of the most common reasons these claims are denied on records review.
