I am NOT an expert in coding breast surgeries ... but here are my thoughts
1) 19370 and 11970 do not appear to bundle when I checked through Encoder Pro
2) Documentation does not seem to match 19370 lay description: An open periprosthetic capsulotomy on the breast is done by making an incision in the skin of the breast, at the site of a mastectomy scar, in the skin fold beneath the breast, or around the nipple. The physician uses a cautery knife to cut into the area of fibrous scarring associated with a breast implant. Incisions are made into the scar (contracted capsule) to cut around its circumference and enlarge the pocket in which the prosthesis is placed. Loosening the capsule relieves pain and tightness caused by the contracture. No tissue is removed. The incision is repaired with layered closure.
3) Documentation does seem to match lay description for CPT 19342: The physician inserts a breast prosthesis after a patient has had previous breast surgery. Delayed insertion is done at a later time, usually after the wound has healed, and may be several months after the original surgery. The physician makes an incision in the fold under the breast or along a previous surgical incision and dissects the tissue and muscle layer free from the chest wall to accommodate a prosthesis positioned under the muscle. As an alternative, the prosthesis may also be positioned between the muscle and the existing breast tissue or skin. The incision is repaired with layered closure.
You cannot code based on what will give you the higer RVU. You have to code based on what the documentation supports.
Did you already appeal with operative note?
Hope this helps.
F Tessa Bartels, CPC, CEMC
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