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Try CasePilotClinical indications. CPT 19318 is the correct code when a surgeon removes excess glandular tissue, fat, and skin from one or both breasts and repositions the nipple-areola complex to a higher location on the breast mound. The standard approach uses a circumareolar incision extending vertically to the inframammary fold (Wise/anchor or vertical/lollipop pattern). Liposuction of the axillary area may occur during the same operative session.
Medical necessity vs. cosmetic. For payer coverage purposes, the operative indication must fall into one of two buckets: (1) symptomatic macromastia with documented physical sequelae, or (2) breast symmetry after mastectomy reconstruction. Symptoms that support medical necessity include chronic back pain, cervicalgia, shoulder pain with bra-strap grooving, intertrigo under the inframammary fold, and paresthesias from brachial plexus compression. Documentation must connect the symptom to the breast size and demonstrate that conservative measures (specialized brassiere support, physical therapy, dermatologic treatment for intertrigo) failed before surgery was pursued.
Technique variants within 19318. The code covers pedicle-based nipple-areola repositioning, which preserves blood supply and nerve function. When the breast is extremely large or pendulous and the nipple must be completely detached and regrafted as a free graft, 19350 (nipple/areola reconstruction) may be separately reportable. Whether free nipple graft is separately billable requires payer-specific verification and clear operative documentation distinguishing the reconstruction component from the reduction.
Gynecomastia vs. macromastia. CPT 19318 covers breast-size reduction for conditions other than gynecomastia. The CPT codebook directs coders to 19318 specifically when breast tissue is removed for size reduction rather than cancer treatment or prevention. ICD-10-CM N62 (Hypertrophy of breast) is the appropriate primary diagnosis and covers gynecomastia, hypertrophy NOS, and massive pubertal hypertrophy.
Setting. This is a physician service code (PC/TC indicator 0). It appears on the ASC-approved procedure list with payment based on OPPS relative weight, so it is commonly performed in both hospital outpatient and ASC settings.
| Code | Description | When to Use Instead |
|---|---|---|
| 19318 | Breast reduction | Symptomatic macromastia or contralateral symmetry after mastectomy; complete tissue excision with nipple-areola repositioning |
| 19316 | Mastopexy | Breast ptosis requiring lift without significant tissue removal; skin excision and reshaping without major glandular reduction |
| 19325 | Mammaplasty, augmentation with implant | Breast augmentation, not reduction; implant insertion is the primary procedure |
| 19350 | Nipple/areola reconstruction | Free nipple graft as a distinct, separately documented component when nipple is completely detached during a reduction with extreme ptosis |
| 15877 | Suction assisted lipectomy, trunk | Axillary liposuction documented as a distinct, separately indicated service at the same session; NCCI edit status must be verified before billing alongside 19318 |
The most critical differentiator is between 19318 and 19316. A mastopexy reshapes and lifts the breast through skin excision and nipple repositioning; a breast reduction does the same while also removing a substantial volume of glandular tissue. When both procedures are performed on the same breast at the same session, the CPT codebook instructs against billing 19380 (revision of reconstructed breast) with 19318 for the same breast, and the overlap between 19316 and 19318 requires that any simultaneous billing be supported by documentation of two distinct, independently indicated procedures.
Bilateral reporting. The CMS bilateral surgery indicator for 19318 is 1, meaning the standard 150% payment adjustment applies for bilateral same-session procedures. Bill 19318-50 as a single line, or report 19318-LT and 19318-RT on separate lines on the same date of service. Never bill two units of 19318 on the same line without a bilateral modifier; this causes claim rejection or overpayment.
Modifier 22. Use modifier 22 only when the operative complexity is substantially greater than typical for 19318: massively enlarged breasts requiring prolonged operative time, free nipple grafting due to extreme ptosis, or significant comorbidities materially increasing surgical risk. Attach a cover letter documenting the specific factors driving increased complexity. Routine bilateral reduction does not support modifier 22.
Co-surgeons (modifier 62). CMS indicator = 1: co-surgeons are payable with supporting documentation. Both surgeons must report 19318-62 and document their distinct operative contributions. Team surgery (modifier 66) has a CMS indicator of 0 and is not permitted for this code.
Assistant surgeon (modifiers 80, 82). CMS indicator = 2 indicates that payment restrictions for assistants at surgery do NOT apply. An assistant surgeon is payable at the standard assistant rate. Report with modifier 80 (or 82 when a qualified resident is unavailable).
Global period management. The 90-day global period includes all pre- and postoperative care. E/M visits for reasons unrelated to the breast reduction within the global period require modifier 24. Return to the OR for a related complication (e.g., wound dehiscence) requires modifier 78; unrelated procedures during the global period require modifier 79.
Axillary liposuction. When 15877 is separately documented and performed at the same session, append modifier 51 to 15877 as the secondary procedure. NCCI PTP edit status for this pair must be verified against current CMS NCCI tables before billing both codes.
Operative report requirements. The single most audited element is tissue weight: the operative report must state the weight in grams removed from each breast. Without a recorded weight, payers cannot verify compliance with their threshold criteria (commonly 500 g per breast for commercial plans) and will deny on audit regardless of whether the surgery was clinically justified. Additional required elements include:
Pre-operative documentation. The medical record should establish: duration and severity of symptoms (back pain, cervicalgia, shoulder grooving, intertrigo); prior conservative treatment and its failure; photographs demonstrating the degree of hypertrophy; and the physician's medical necessity determination linking the symptom burden to surgical intervention. Some MAC LCDs and commercial policies also require BMI documentation and evidence that weight reduction was considered or attempted.
Audit triggers specific to 19318. Auditors flag claims where: (1) the operative report lacks tissue weights; (2) the diagnosis is coded only as N62 without secondary codes supporting functional impairment (e.g., M54.2, M54.59, L30.4); (3) 19316 and 19318 are billed together for the same breast without distinct documentation; and (4) bilateral modifier is missing while two units are billed.
Medicare. Medicare considers bilateral breast reduction cosmetic under SSA §1862(a)(10) and does not cover it absent a specific exception. The primary covered exception is contralateral breast reduction performed for symmetry following mastectomy and reconstruction, which is mandated by the Women's Health and Cancer Rights Act of 1998. Coverage determination is governed by MAC-level Local Coverage Determinations rather than a national NCD. Coders should search the CMS Medicare Coverage Database by jurisdiction for the applicable LCD (search terms: "reduction mammaplasty" or "breast reduction"). MAC LCDs commonly specify minimum tissue resection thresholds, BMI criteria, and required documentation of conservative treatment failure. The ASC payment indicator confirms 19318 is payable in ASC settings.
Commercial payers. Most commercial plans cover medically necessary reduction mammaplasty with prior authorization. Coverage criteria typically parallel MAC LCD requirements: documented symptoms, tissue weight thresholds (commonly 500 g or more per breast), failure of conservative management, and pre-operative photographs. Prior authorization must be obtained before surgery; retroactive authorization is rarely granted for elective surgical procedures. Verify plan-specific thresholds before surgery, as some plans use body-surface-area-adjusted formulas rather than a flat gram threshold.
Medicaid. State Medicaid programs vary. Many cover medically necessary reduction mammaplasty with prior authorization, but coverage criteria, documentation requirements, and tissue weight thresholds differ by state. Managed Medicaid plans may impose additional restrictions beyond the base state policy.
Missing tissue weight documentation Payer auditors and MAC contractors routinely recoup payments when the operative report does not document the weight of tissue removed. This is the most preventable denial for 19318. Prevention: confirm operative reports are templated to include tissue weight from pathology or intraoperative scale measurement before claim submission. Do not release the claim until the operative report is complete.
Medical necessity not established Payers deny when the claim lacks documentation connecting the diagnosis to a functional impairment. Coding N62 alone without secondary diagnosis codes for the specific symptoms (back pain, cervicalgia, intertrigo) does not adequately support medical necessity. Prevention: code all documented functional symptoms as secondary diagnoses. Ensure the pre-operative notes and operative report explicitly link the breast size to the symptom burden.
Incorrect bilateral reporting Billing 19318 with two units on a single line (instead of modifier 50 or LT/RT) triggers claim rejection or system-level denials. Prevention: bill 19318-50 as a single line, or use separate LT/RT lines depending on payer preference. Verify payer billing guidelines for bilateral reporting before submission.
Bundling denial: 19316 with 19318 When both mastopexy and breast reduction are billed for the same breast at the same session without documentation of a separately indicated procedure, payers deny 19316 as included in 19318. Prevention: if a distinct mastopexy component was performed and separately documented, verify current NCCI PTP edit status before billing both. Attach operative documentation clearly describing the separate, independently indicated mastopexy procedure.
Medicare cosmetic denial Bilateral reduction billed to Medicare without a covered indication (e.g., symmetry after mastectomy) will be denied as cosmetic. Prevention: confirm Medicare coverage eligibility before scheduling. For symmetry-after-mastectomy cases, use N65.1 (Disproportion of reconstructed breast) as the primary diagnosis and document the mastectomy history and reconstruction in the medical record. Issue an ABN if the cosmetic determination applies and the patient wants to self-pay.
Scenario: A 35-year-old woman with documented cervicalgia, bilateral shoulder grooving from bra straps, and chronic intertrigo under both inframammary folds undergoes bilateral reduction mammaplasty. The operative report records 620 g removed from the right breast and 580 g from the left. Prior authorization from a commercial plan was obtained preoperatively.
Correct coding: 19318-50 / N62 (primary), M54.2, L30.4
Why: Bilateral modifier 50 is used because both breasts were reduced at the same session (bilateral indicator = 1). Secondary diagnoses document the specific functional symptoms driving medical necessity beyond the hypertrophy diagnosis alone.
Scenario: A 58-year-old woman who underwent left mastectomy and TRAM flap reconstruction two years ago now has right breast size disproportionate to the reconstructed left breast. She undergoes right breast reduction for symmetry. She is enrolled in Medicare.
Correct coding: 19318-RT / N65.1 (primary)
Why: The WHCRA mandates coverage for symmetry procedures after mastectomy reconstruction. Use N65.1 (Disproportion of reconstructed breast) rather than N62 to identify this as a reconstructive symmetry procedure. The modifier RT documents the laterality; modifier 50 does not apply because only one breast was operated on. Medicare coverage documentation must reference the mastectomy history.
Scenario: During a bilateral reduction mammaplasty, the surgeon also performs separate suction-assisted lipectomy of the bilateral axillary regions to improve lateral contour. The operative report documents both the breast reduction and the axillary liposuction as distinct procedures with separate descriptions of technique and anatomical site.
Correct coding: 19318-50, 15877-51 (contingent on NCCI PTP edit verification) / N62 (primary), secondary symptom codes as applicable
Why: Axillary liposuction may be separately reportable when clearly documented as a distinct component. Modifier 51 applies to the secondary procedure under standard multiple-procedure rules. NCCI PTP edit status for the 19318/15877 pair must be confirmed before billing both; if an edit exists without a modifier indicator permitting override, the axillary liposuction cannot be separately reported.
Scenario: A surgeon performs bilateral reduction mammaplasty and documents skin excision and lifting components consistent with mastopexy in the same operative note. The coder considers billing both 19318-50 and 19316-50.
Correct coding: 19318-50 only / N62 (primary), secondary codes as applicable
Why: Mastopexy components are integral to breast reduction. The CPT codebook instructs that 19316 and 19318 should not be reported together for the same breast unless the mastopexy represents a separately indicated, distinctly documented procedure. When the operative note describes a single unified reduction with skin lifting, 19318 captures the complete service.
© Copyright 2026 American Medical Association. All rights reserved.
The procedure described by CPT® Code 19318 refers to breast reduction surgery, clinically known as reduction mammaplasty. This surgical intervention is performed to reduce the size of the breasts by removing excess glandular tissue, fat, and skin. The operation begins with the surgeon making a precise incision that circles the areola, extends downward, and follows the natural contour of the breast crease. This careful incision design is crucial for achieving an aesthetically pleasing result while minimizing visible scarring. During the procedure, the surgeon meticulously removes the excess tissue and repositions the nipple and areola to a higher, more youthful location on the breast. The surrounding skin is then brought down and around the areola to create a new breast contour that is both natural and proportionate to the patient's body. In some cases, liposuction may be employed to eliminate additional fat from the axillary area, further enhancing the overall outcome. It is important to note that in most instances, the nipple remains attached to its blood supply and nerves, preserving sensation and function. However, in cases where the breasts are particularly large or pendulous, the nipple and areola may need to be completely detached and grafted to a new position. Throughout the procedure, bleeding is managed using electrocautery, and the incision is subsequently closed with sutures to promote healing and minimize complications.
© Copyright 2026 Coding Ahead. All rights reserved.
The procedure of breast reduction surgery, as indicated by CPT® Code 19318, is typically performed for several specific reasons, including:
The breast reduction procedure involves several critical steps, which are outlined as follows:
After the breast reduction surgery, patients are typically monitored in a recovery area to ensure they are stable before being discharged. Post-procedure care includes managing pain with prescribed medications and following specific instructions regarding activity restrictions. Patients are advised to avoid strenuous activities and heavy lifting for a designated period to promote healing. Follow-up appointments are essential to monitor the healing process and address any concerns. Patients may also receive guidance on scar care to optimize the aesthetic outcome of the incisions. Overall, the expected recovery time varies, but many patients can return to normal activities within a few weeks, depending on their individual healing progress.
| Short Descr | BREAST REDUCTION | Medium Descr | BREAST REDUCTION | Long Descr | Breast reduction | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1A - Major procedure - breast | MUE | 1 | CCS Clinical Classification | 175 - Other OR therapeutic procedures on skin and breast |
| 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | RT | Right side (used to identify procedures performed on the right side of the body) | LT | Left side (used to identify procedures performed on the left side of the body) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | GC | This service has been performed in part by a resident under the direction of a teaching physician | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | AR | Physician provider services in a physician scarcity area | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | GA | Waiver of liability statement issued as required by payer policy, individual case | GJ | "opt out" physician or practitioner emergency or urgent service | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | GZ | Item or service expected to be denied as not reasonable and necessary | KX | Requirements specified in the medical policy have been met | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | SG | Ambulatory surgical center (asc) facility service | U7 | Medicaid level of care 7, as defined by each state | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2021-01-01 | Changed | Code changed. |
| Pre-1990 | Added | Code added. |
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