Breast Reconstruction Coding: Stages, Flaps, and Symmetry Procedures
Breast reconstruction is coded by technique and by stage, and understanding the symmetry rule is what makes the full claim.
By technique
- 19357 — tissue expander placement (first stage)
- 19340 / 19342 — implant, immediate / delayed
- 19361 — latissimus dorsi flap reconstruction
- 19367–19369 — pedicled TRAM flap
- 19364 — free flap (including DIEP) with microvascular anastomosis
Acellular dermal matrix used in implant-based reconstruction is reported with its add-on (+15777). Nipple reconstruction (19350) and areola tattooing (11920–11922) are later, separately reportable stages.
The symmetry rule
Under the Women's Health and Cancer Rights Act, procedures on the contralateral breast to achieve symmetry — reduction (19318), mastopexy (19316), or augmentation (19325) — are covered and separately codable on a reconstructed patient. Document the symmetry indication.
Clinical Capture identifies the reconstruction technique and stage, adds the ADM and symmetry codes when the note supports them, and keeps the coding within the reconstructive framework.
This article is educational and not coding, billing, or legal advice. Always verify codes and values against the current CPT®, ICD-10-CM, and CMS Physician Fee Schedule, follow NCCI edits and payer policy, and confirm with a certified coder before submitting a claim. Document only work that was actually performed.