General Surgery Coding Alert

Your general surgeon may perform breast reconstruction following cancer, infection, trauma, or burns, or in some cases, strictly for cosmetic reasons. Make sure you capture appropriate implant pay, when that's part of the surgical scheme, by following our experts' tips.

Breast implants commonly serve two functions ��" cosmetic breast enhancement or breast reconstruction following a disfiguring event such as mastectomy for cancer or a traumatic injury.

CPT divides implant codes based on the function, so that's the first distinction you need to make when selecting the proper code.

Differentiate augmentation: Use 19325 (Mammoplasty, augmentation; with prosthetic implant) when the surgeon implants a breast prosthesis for breast enlargement. "Code 19325 describes cosmetic implants only," emphasizes John F. Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop and Associates.

When the surgeon implants a prosthesis to reconstruct the breast following mastectomy, you need to look elsewhere for a code. For silicone or saline implants involved in reconstruction, CPT provides the following two codes:

19340 -- Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction

19342 -- Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction.

CPT provides 19340 and 19342 for breast prosthesis associated with mastectomy or mastopexy. You'll decide between those two codes based on when your surgeon performs the implant procedure.

How it works: For patients whose physiology will accommodate a full-size saline- or silicone-filled prosthesis, your surgeon may place the implant immediately following the mastectomy. "If the surgeon inserts a breast implant at the same operative session as the mastectomy, you should report 19340," Bishop says.  "For our mastectomy patients who opt for reconstruction, immediate treatment is the most common choice," says Lynn Woolard, practice manager for General and Vascular Surgery in Elgin, Ill.

Look for 'delayed' code: On the other hand, the surgeon sometimes closes the surgical site following mastectomy and the patient goes home to heal for some period of time. If the patient returns at a later date for a breast reconstruction that involves implant placement, you should list 19342 for the insertion. Using this code correctly is important because the procedure is more complicated and pays significantly more, according to Bishop -- $725 for 19340 versus $868 for 19342, based on the Medicare physician fee schedule facility national values using conversion factor 36.0846.

Mastopexy can start the clock: You won't always choose "immediate" (19340) or "delayed" (19342) based  on when the patient had a mastectomy. The codes state, "following mastopexy, mastectomy or in reconstruction," so you might still use 19340 even if the implant happens long after a mastectomy. For instance, you should use 19340 instead of 19342 for inserting a breast prosthesis at the same operative session as a revision (mastopexy), even if the patient had a prior mastectomy at the site.

Use additional code(s) for reconstruction: If the surgeon performs a distinct reconstruction procedure at the same time as the prosthesis insertion, you should separately report the reconstruction. For instance, when the surgeon inserts an implant during a latissimus dorsi flap reconstruction, you should list 19340 in addition to 19361 (Breast reconstruction with latissimus dorsi flap, without prosthetic implant).

When your surgeon performs a recontruction using a tissue expander, you'll report 19357 (Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion). Unlike implant insertion coding, you'll use the same expander code whether the procedure is "immediate" or "delayed" following a mastectomy. During the 19357 procedure, the surgeon places a flat, balloon-like device through an incision and then increasingly inflates or fills it over time. Inserting a tissue expander is a very common post-mastectomy reconstruction procedure, according to Woolard.

Keep in mind: The descriptor for 19357 states, "including subsequent expansion." That means you cannot separately bill when the patient returns for gradual expansion. Surgeons usually fill the tissue expander to accomplish stretching the overlying tissue to a size that is suitable for an implant insertion.

Add replacement: If the tissue expander is temporary, you should report its removal and replacement with a permanent prosthesis using 11970 (Replacement of tissue expander with permanent prosthesis).

The breast implant and reconstruction codes are unilateral -- they describe the service for one breast. Some payers expect you to append modifier LT (Left side) or RT (Right side) to the procedure code.

If the surgeon performs any of these procedures on both breasts, you should append modifier 50 (Bilateral procedure) to indicate that fact.