Don’t lose 19342 pay for delayed insertion.
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.
Tip 1: Prosthesis’ Purpose Drives Coding
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.
Tip 2: Timing is Everything for Implant Placement
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.
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