# breast implants



## sfry (Apr 17, 2008)

A patient came to the hospital due to painful breast implants.  She is status post bilateral mastectomies with immediate implants.

The surgeon removed the implants, performed a capsulotomy, and placed new, larger implants.  I have assigned the following codes, and would like other opinions on how to code this case.

19328 - Removal of intact mammary implant
19370 - Open periprosthetic capsulotomy, breast
19342 - Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction

Thanks, 
Shannon


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## codegirl0422 (Apr 17, 2008)

would you not use 
19371 for the removal
and then 19325 for replacement?

19328 includes dissection of muscle, fat, and breast tissue, 19371 is where the contracted capsule is excised from the breast tissue and the prosthesis is removed.

My understanding of 19342 is it is used when the breast prosthesis is placed after a previous breast surgery (mastectomy) where there is delayed insertion of implants/prosthesis, no implants removed. 19342 would not be used since implants had already been put in after the mastectomies.

This is my understanding, however, I have only been doing coding and billing for plastic surgery for 1 1/2 months. Hope it helps.

Joyce


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## sfry (Apr 23, 2008)

In this case, 19371, capsulectomy was not performed.  Only the capsulotomy to enlarge the incision to place the larger, secondary implant.


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## Bella Cullen (Apr 23, 2008)

I would do 19328-removal, 19340-immediate insertion, because you are removing and replacing in the same surgical session, and then 19370-for capsulotomy. 
There is not an edit either for these. Hope this helps.


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## bench (Jun 17, 2008)

I would code the same, 19328, 19370 and 19340. With regards to 19370 look first in the op-report where the capsulotomy was done. If it was done along the previous incision site, you cannot report this anymore since 19328 is removal and before you can go to the implant, you have to incise the capsule also. In this case you cannot report 19370. If the capsule was incise maybe lateral, superior, or medial as long as it is away from the previous incision site. I hope this make sense.


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## amitjoshi4 (Jun 17, 2008)

sfry said:


> A patient came to the hospital due to painful breast implants. She is status post bilateral mastectomies with immediate implants.
> 
> The surgeon removed the implants, performed a capsulotomy, and placed new, larger implants. I have assigned the following codes, and would like other opinions on how to code this case.
> 
> ...


 
19328 and 19342 are the applicabe codes here. Since the new implants are placed after the mastectomy was done and subsequent implants were placed. This time this is delayed insertion. See the CPT assistant article below to avoid any confusion

*Reporting Breast Reconstruction Codes*
*CPT Assistant, August 2005, Volume 15, Issue 8, pages 1-3*

To complement our April 2005 update focusing on new breast excision guidelines and in response to reader requests, we present a review of the breast reconstruction codes, applicable global concepts, and the elements inclusive of breast reconstruction codes.

*Introduction*
Breast reconstruction is a surgical procedure designed to recreate a breast mound following a mastectomy performed to treat cancer or other disease, or a mastectomy performed for prophylactic purposes. Reconstruction can be accomplished by using a prosthesis (implant) or the patients own (autogenous) tissue, such as a flap of muscle with or without overlying skin, that is moved from its native site and transferred to the breast area recipient site. In some cases, a combination of both may be used. The reconstructed breast is sized and contoured to match, as closely as possible, the remaining breast. Occasionally the remaining breast may also require surgical contouring (coded separately).

*Timing*
Breast reconstruction can be _immediate_ (performed at the time of the mastectomy procedure) or _delayed_ (performed at a later date). From a CPT coding perspective, specific codes are used to identify immediate (19340) and delayed (19342) breast _implant_ reconstruction procedures. All other breast reconstruction procedures are identified by type of reconstruction performed (eg, free flap, pedicled flap) and are reported on that basis, regardless of whether the reconstruction is immediate or delayed.

*Prosthesis or Implant*
When a saline or silicone-filled breast prosthesis is inserted at the time of mastectomy, it is considered an _immediate _reconstruction and is coded _19340, Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction_. When prosthetic reconstruction is performed at a later date, it is coded _19342, Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction. _


*Flaps*
CPT breast reconstruction codes 19361, 19364, 19367, 19368, and 19369 are global codes and include the following elements:


Elevation and transfer of the flap
Closure of the donor site
Breast contouring
Insertion of breast implant or prosthesis, when performed
Code _19361, Breast reconstruction with latissimus dorsi flap, with or without prosthetic implant_, describes breast reconstruction using a flap that includes the latissimus dorsi, a large muscle on the back. The muscle and overlying skin are elevated and passed through a tunnel under the skin to the chest where it is placed between the chest muscle and skin to form the new breast mound.

Code _19364, Breast reconstruction with free flap_, is used to report placement of a muscle flap freed completely from its native site that is transferred to the chest for the reconstruction. Examples are a free transverse rectus abdominis myocutaneous (TRAM) flap or free gluteal flap. This code is global and includes the previously listed elements as well as microvascular transfer (microvascular suture anastomosis of blood vessels in the flap to blood vessels at the recipient site on the chest). Code _69990, Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure)_, is not reported in conjunction with code 19364.

TRAM flap codes 19367, 19368, and 19369 additionally include the following:


Creation of the breast pocket
Elevation of the abdominal flap
Muscle dissection
Flap transfer
Fascial closure (donor site) with or without mesh
Abdominal closure including umbilicoplasty
Breast contouring
Code _19367, Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site_, describes breast reconstruction with a single pedicle TRAM flap. When the flap is supercharged, an additional artery is included with the flap when it is harvested in order to provide more blood supply to the flap. The additional artery is anastomosed to an artery at the recipient site using microvascular techniques. The supercharged breast reconstruction is reported using only one code: code _19368, Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; with microvascular anastomosis (supercharging)_. Because microvascular anastomosis is included in code 19368, code 69990 is not reported in conjunction with it.

Code _19369, Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site_, is intended to be reported for a unilateral breast reconstruction using both rectus muscles.

*Unilateral or Bilateral Procedures*
When breast reconstruction is performed unilaterally, the applicable HCPCS Level II modifier-LT (left) or RT (right)-is appended to the appropriate code for the reconstruction procedure.

When the same breast reconstruction procedure is performed bilaterally at the same operative intervention, modifier 50 is appended to the appropriate reconstruction code (eg, bilateral breast reconstruction using a single pedicle TRAM flap on each side would be coded: 19367 with modifier 50 appended).


CPT Assistant, August 1996, Volume 08, Issue 6, page 8 
_What is the difference between CPT code 19340_,_ immediate insertion of a breast prosthesis and CPT code 19342_,_ delayed insertion of a breast prosthesis?_
CPT code 19340, which describes "immediate" insertion of breast prosthesis is defined as the insertion of the breast prosthesis performed at the same operative session as the breast removal or revision procedure (such as a mastectomy, mastopexy or reconstruction). CPT code 19342, which describes "delayed" insertion is defined as insertion of the breast prosthesis at a later time, such as after the wound has healed, which can be several months after the original surgery.

Thank You


2005 American Medical Association


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## bench (Jun 17, 2008)

try cpt codes 19380 and 19370. 19380 is the revision of breast reconstruction.


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## oyboutj (Dec 10, 2020)

The original post was long ago, but I thought it worth updating

The answer is 19342.  This includes removal of the existing implant/TE and revision to the breast to accommodate and properly seat the new implant.

CPT Assistant
Year: 2013

Issue: January

Pages: 15-16

Title: Frequently Asked Questions

Body:
Surgery: Integumentary System

Question:The August 2005 edition of the CPT Assistant (page 2) included the reporting of temporary tissue expander replacement, as excerpted:“If a temporary tissue expander has been used, it is removed after the skin has stretched sufficiently and is replaced with a permanent breast prosthesis during a second operation. This procedure is generally coded [with code] 11970, Replacement of tissue expander with permanent prosthesis. Code 11970 is a global service and includes removal of the temporary expander, which is not to be reported separately. In certain instances, considerable capsular adjustments are necessary to allow proper placement of the prosthesis within the fibrous capsule that has formed around the expander, and with appropriate documentation in the operative report, code 19342 is sometimes used instead of 11970.” Would the reference to the “considerable capsular adjustments” involve capsulotomy or capsulectomy for which code 11970 may be reported in addition to code 19371, Periprosthetic capsulectomy, breast?

Answer:No. It was intended that code 11970 includes some minor adjustments to the capsule. However, when significant adjustments are made to the capsule, many of which comprise a significant part of the procedure, and when appropriately documented, code 19342, Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction, may be reported to represent the additional maneuvers that involve more surgeon time and work. For example, sometimes the capsule must be significantly modified, the infra-mammary crease must be lowered or raised, or partial or total capsulectomy must be performed.

Another example of the type of work associated with the use of code 19342 is breast reconstruction with expander in a patient undergoing postoperative expansion. When the tissue expander is replaced, it may be that the capsule is found to be very tight and multiple radial incisions may be required in the capsule to accommodate the permanent prosthesis and form a symmetric contour to the opposite breast. CPT code 11970 alone does not account for this additional work, which is over and above removal of an expander and replacement with a permanent implant.


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