Breast surgery can be a challenge to code. Some payers, for example, won't cover reconstructive procedures on prior breast augmentations, while others will cover the reconstructive procedures, but not the implant replacement. Here's the latest on recent coding clarifications, as well as important details regarding implants and payer considerations.
Medicare Reimbursement for Breast Surgery
As the field of breast reconstruction and revisional surgery has evolved, so, too, have breast surgery CPT codes in both their purpose and intent.
| Procedure | CPT Code | ASC | OPPS | APC | Multiple Discount |
| Autologous fat transfer | 19366 | $1,379.81 | $2,458.99 | 0029 | Yes |
| Tissue expanders | 19357 | $3,565,14 | $4,562.00 | 0648 | Yes |
| Soft tissue reinforcement | 15777 | $623.76 | $1,111.61 | 0136 | Yes |
| Replacement of tissue expander with permanent prosthesis | 11970 | $1,928.93 | $3,437.59 | 0051 | Yes |
| Revision of reconstructed breast | 19380 | $1,815.79 | $3,235.96 | 0030 | Yes |
| Nipple/areola reconstruction | 19350 | $1,045.25 | $1,862.77 | 0028 | Yes |
Autologous fat transfer
Although most breast reconstructions are performed with implants, some patients are opting for autologous fat transfer (AFT) procedures. In these procedures, the patient wears an external tissue expander such as the Brava device for about a month before the procedure. During the procedure, liposuction is performed to harvest fat for the breast reconstruction. The fat is centrifuged and placed into syringes, which are used to transfer the fat into the breast.
When AFT is the sole method of reconstructing the breast, report code 19366 [Breast reconstruction with other technique], according to the December 2011 CPT Assistant. The liposuction procedure to harvest the fat is not separately reported. Under both the ASC and OPPS payment systems, a multiple procedure reduction applies, which means the procedure on the contralateral breast is reduced for bilateral procedures performed on the same date of service.
There are a few things to consider with this procedure. Not long ago, placing fat grafts into the breast was not considered safe. Fat necrosis was common, and that complication could interfere with subsequent mammograms. With current techniques, including low suction pressure for the harvest of fat, centrifuging of the fat to remove fluids and injection of smaller fat particles into the breast, survival of the fat cells has improved significantly. However, this careful attention to the harvesting and processing of the fat increases operating times. Surgeries can average more than 1 hour and some can take up to 6 hours, increasing both the risk to the patient and the expense to the facility. Pay careful attention to patient selection criteria, and closely analyze the operating expenses for this procedure before adding it to your facility's offerings.
RECONSTRUCTIVE OR COSMETIC?
How to Code Replacement Breast Implants
Medicare Reimbursement for Replacement Breast Implants
| CPT Code | ASC | OPPS | APC |
| 19325 | $3,565.14 | $4,562.00 | 0648 |
| 19340 | $1,815.79 | $3,235.96 | 0030 |
— Denis Rodriguez, CPC-H
Internal tissue expanders
To prepare a mastectomy patient for subsequent breast implants, it's common to place internal tissue expanders. Whether it's performed immediately after mastectomy or it's delayed until chemotherapy or radiation therapy treatments are completed, use 19357 [Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion] to report this procedure. When performed in an ASC, the Medicare national payment rate for 19357 is $3,565.14. Under the Medicare ASC payment system, this code has a payment indicator of J8, meaning it's a device-intensive procedure and payment for the expanders is included in the procedure fee. When performed in a hospital outpatient department, OPPS assigns this code to APC 0648, which is paid at $4,562.00. Report C1789 for each implant in the HOPD setting; but because OPPS assigns an N status indicator to this code, its payment is considered packaged into the fee for the main procedure. Whether done at an ASC or HOPD, the multiple procedure discount applies. Report the expanders to C1789 [Prosthesis, breast (implantable)] or L8600 [Implantable breast prosthesis, silicone or equal] because most payers that don't package or bundle them into the surgical fee, as the expander is, in essence, an adjustable saline breast prosthesis.
Soft tissue reinforcement
Use 15777 to report any soft tissue reinforcement of the breast with biologic implants such as Alloderm or Dermagraft. You must report this add-on code along with the code for the main procedure (19357, for example). Some payers may deny payment for the soft tissue reinforcement code, but may pay for the biologic implant tissue, says Raymond Janevicius, MD, the American Society of Plastic Surgeons's representative to the American Medical Association's CPT Advisory committee.
Medicare Reimbursement for Biologic Breast Implants
| Biologic Implant | HCPCS code | ASC | OPPS | APC |
| Alloderm | Q4116 | $31.69* | $32.21* | 1270 |
| Dermagraft | Q4106 | $42.55* | $42.57* | 1245 |
* Per square centimeter
Revision of the reconstructed breast
Although more a staged procedure than a revisional procedure, we're including code 11970 [Replacement of tissue expander with permanent prosthesis] because it's often accompanied by revisional procedures that can make coding these procedures complicated.
After a tissue expander has adequately created a space for implant placement, the surgeon will bring the patient in for removal of the expander and placement of the permanent implant. Code 11970 includes minor adjustments to the capsule during the expander removal and implant placement. However, significant adjustments such as lowering or raising the inframammary crease, significant partial or total capsulectomy, or multiple capsulotomies to achieve symmetry or accommodate the prosthesis aren't included in code 11970, according to the January 2013 CPT Assistant. In such a case, some payers require the procedure to be reported to 19342, as the AMA recommends, while others may prefer the reporting of 11970 along with the capsulotomy or capsulectomy codes, says Dr. Janevicius. He adds that the extent of the capsulotomies and capsulectomies should be well described in the note. Document the area being adjusted along with the intent and/or effect of the procedure; a statement such as "capsulotomy was performed" does not suffice. Because code 19342 includes considerable capsular adjustments in preparation for delayed implants, you wouldn't code capsulotomies in addition.
When coding for capsulotomies, capsulectomies and implant removal, keep these guidelines in mind:
Code 19380 [Revision of reconstructed breast] is a non-specific code intended to capture revisional procedures other than capsulotomies and capsulectomies. As the code descriptor states, in order to report 19380, the procedures must be performed on a breast that has already been reconstructed. According to the March 2013 Plastic Surgery News, this code may include the following procedures:
Medicare Reimbursement for Capsulotomies, Capsulectomies and Implant Removal
| CPT Code | ASC | OPPS | APC | Multiple |
| 19328 | $1,379.81 | $2,458.99 | 0029 | Yes |
| 19342 | $3,565.14 | $4,562.00 | 0648 | Yes |
| 19370 | $1,379.81 | $2,458.99 | 0029 | Yes |
| 19371 | $1,379.81 | $2,458.99 | 0029* | Yes |
For reconstruction of the nipples, which is not included in implant placement, report code 19350 [Nipple/areola reconstruction]. Any flaps/tissue rearrangement, grafts, tattooing or other procedure inherent to nipple/areola reconstruction is included in this code and not separately reported, according to the January 2013 CPT Assistant.
Communicate with the payer
Payers differ on the types of procedures they cover and how they want certain procedures reported. Be sure to get your breast procedures pre-authorized in writing. Your request for pre-authorization should clearly and accurately describe the procedures you intend to perform. Coding accurately for breast reconstruction and revision can be a challenge, but with a clear understanding of coding guidelines, detailed and thorough documentation of the procedures and a pre-authorization process in place, your facility can get reimbursed its fair due for these procedures.
