Forum - Questions & Answers

Sep 16th, 2022 - Ellie

Breast reconstruction CPT codes

There is so little allowable to add to 11970 (tissue expander exchange to silicone implant)for all of the revisions that are done at that time - really just capsular work (19370) and fat grafting (15771) - how do I bill for changes to the skin envelope and repositioning of the nipple areola ? Very common revisions, but we are not allowed to use 19380?!

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Sep 21st, 2022 - ChrisW   247  1 

re: Breast reconstruction CPT codes

Without knowing the reason behind the procedure and what was actually done, the following may or may not be correct in your situation. There is a lot going on here. Is the procedure a reconstruction? If so, then 19380 Covers the revision, re-advancement, and/or re-inset of flaps or capsular revision.
There is an NCCI edit stating not to bill 19380 with 19370 (Re-construction) as only 19380 (Capsular work) will be paid. (- This edit CAN be overridden via CCI-associated modifiers WHEN APPROPRIATE.)
Fat Grafting:  Codes 15769, 15771, and 15772 is be reported for autologous fat grafting for reconstructive breast surgery.  Liposuction is not separately reported.  Remember to bill for each additional 50cc, if applicable, using the add-on code 15772.
The Nipple/areola reconstruction can be reported with 19350 as this is not included in the implant replacement. 
Replacement of tissue expander with a permanent implant, 11970 has a J1 APC status indicator, meaning it is packaged and paid through a comprehensive APC (generally, no separate payment will be made). 
I would encourage you to consult with the payer's policy; they may or may not follow APC rules or may have a different policy. 
Find-A-Code.com offers Commercial Payer Policies for all major payers, or contact the payer directly. 
 
 
 

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