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19366 vs 19357

louise Posted Wed 09th of January, 2019 16:21:12 PM
breast tissue expander port located with Sterile technique, used to inject with saline into breast
SuperCoder Answered Thu 10th of January, 2019 04:18:29 AM

Breast reconstruction surgery is done mostly following mastectomy. Mastectomy results in partial or complete loss of breast mass. Reconstruction surgery helps in regaining the lost mass and shape. In the CPT 19366 (Breast reconstruction with other technique), breast reconstruction may be done using implants such as silicone gel capsules or saline implants. It can also be done using the patient's own soft tissue (muscle and fat) graft harvested from other sites of the body such as the abdomen, thigh, buttock, etc. The reconstruction can be done immediately following mastectomy or it can be done at a later stage depending upon the decision of the patient. The reconstruction method involves preplanning that takes into account various factors such as the mode of reconstruction preferred by the patient (i.e., through the use of implants or autogenous tissue), the shape of the contralateral breast (existing healthy breast), the overall body structure of the patient, and availability of sufficient body tissue for autogenous graft.


Whereas, in CPT 19357 (Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion), the provider may perform this procedure immediately after mastectomy or later, such as three to four weeks post mastectomy. Physician places a tissue expander into the skin and pectoralis major muscles of the chest. The patient has the procedure to increase the size and volume of the breast to make space for a permanent implant following a previous mastectomy. He also may inject additional saline over a period of weeks or months to create additional tissue expansion.  The provider performs the subsequent expansion portion of the procedure over a period of several weeks during the global period. It is suggested to match the operative documentation and select the code according to the above description of procedure. However, as per provided information, CPT 19357 seems appropriate.

Hope this helps!

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