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The procedure described by CPT® Code 19361 involves breast reconstruction utilizing the latissimus dorsi flap technique. This surgical intervention is typically performed following a mastectomy, where the breast tissue has been surgically removed due to cancer or other medical conditions. The latissimus dorsi muscle, located in the back, is utilized to reconstruct the breast by transferring skin, muscle, and subcutaneous fat from the back to the chest area. The process begins with the surgeon making an incision in the back to access the latissimus dorsi muscle. A portion of this muscle, along with the overlying skin and fat, is carefully dissected and then tunneled under the skin of the axilla (armpit) to reach the defect on the chest wall. This flap remains vascularized, as it is still connected to the thoracodorsal artery, ensuring an adequate blood supply to the transferred tissue. The use of a latissimus dorsi flap allows for enhanced aesthetic outcomes in breast reconstruction, providing better coverage and a more natural shape compared to implants alone. In some cases, this flap may be used in conjunction with a tissue expander or implant to achieve the desired breast volume. The procedure also includes the closure of the donor site with layered sutures, ensuring proper healing. Additionally, a small section of skin may be excised from the breast area to create a graft for the areola, which is sutured in place, with the nipple often reconstructed at a later stage through tissue rearrangement. This comprehensive approach to breast reconstruction aims to restore not only the physical appearance but also the emotional well-being of the patient following a mastectomy.
© Copyright 2025 Coding Ahead. All rights reserved.
The latissimus dorsi flap procedure, as described by CPT® Code 19361, is indicated for patients who have undergone a mastectomy and require breast reconstruction. The following conditions may warrant this surgical intervention:
The procedure for breast reconstruction using the latissimus dorsi flap involves several critical steps, each designed to ensure the successful transfer of tissue and optimal aesthetic results:
After the latissimus dorsi flap procedure, patients can expect a recovery period that may involve monitoring for complications such as infection or flap failure. Post-operative care typically includes pain management, wound care, and follow-up appointments to assess healing. Patients may also receive instructions on activity restrictions to ensure proper recovery. The final aesthetic results may take time to fully manifest as swelling subsides and the tissues settle into their new position. Additionally, the reconstruction of the nipple and areola may occur in subsequent procedures, further enhancing the cosmetic outcome of the breast reconstruction.
| Short Descr | BRST RCNSTJ LATSMS DRSI FLAP | Medium Descr | BREAST RECONSTRUCTION W/LATISSIMUS DORSI FLAP | Long Descr | Breast reconstruction; with latissimus dorsi flap | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1A - Major procedure - breast | MUE | 1 | CCS Clinical Classification | 175 - Other OR therapeutic procedures on skin and breast |
| RT | Right side (used to identify procedures performed on the right side of the body) | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | GZ | Item or service expected to be denied as not reasonable and necessary | KX | Requirements specified in the medical policy have been met | LT | Left side (used to identify procedures performed on the left side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2021-01-01 | Changed | Code changed. |
| 2007-01-01 | Changed | Code description changed. |
| 1992-01-01 | Added | First appearance in code book in 1992. |
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