CPT® Code 19380

Quick Reference

• Code definition: CPT 19380 captures revision of a previously reconstructed breast involving significant tissue removal and/or flap re-advancement (autologous cases) or significant capsular revision combined with soft tissue excision (implant-based cases).
• Key billing rule: 90-day global period applies; revisions performed within 90 days of the original reconstruction require modifier -58, -78, or -79 to avoid bundling denial.
• Modifier essentials: Modifier -50 triggers the 150% bilateral payment adjustment when both reconstructed breasts are revised; -LT/-RT preferred by some MACs. Modifier -58 for planned staged revision; -78 for unplanned return to OR during global period.
• Documentation must-have: The operative report must explicitly describe the nature and extent of the revision, quantifying tissue removed or detailing flap re-advancement. For implant-based cases, both the capsular work and the soft tissue excision must be documented separately.
• Top confusion point: For implant-based reconstructions, 19380 requires BOTH significant capsular revision AND soft tissue excision. Capsular work alone belongs under 19370 or 19371. Reporting 19380 when only capsular revision was performed is the most common upcoding risk in this code family.
• Payer alert: Under the Women's Health and Cancer Rights Act (WHCRA) of 1998, group health plans covering mastectomy must cover all stages of reconstruction including revision surgery. Despite this mandate, medical necessity documentation and specifics of the revision type must still support the claim on submission.
• MUE: 1 unit per date of service per side. Co-surgeons (-62) and team surgery (-66) are not permitted per MPFS indicators.

When to Use This Code

Clinical Indications

Autologous reconstruction revision qualifies under 19380 when the surgeon performs significant tissue removal and/or re-advances or re-insets the flap. Common clinical drivers include excess flap fullness, contour irregularities, breast asymmetry relative to the contralateral side, fat necrosis within the flap, and partial flap volume loss. Radiation-induced fibrosis or deformity and weight-change-driven size discrepancy are also accepted indications. Either element alone, significant tissue removal or flap re-advancement, may qualify if the documentation supports that the revision substantially altered the breast mound.

Implant-based reconstruction revision qualifies when the surgeon performs significant capsular revision combined with soft tissue excision. Both components must be present. Typical scenarios include Baker Grade III or IV capsular contracture accompanied by skin or soft tissue excision, implant malposition requiring capsular manipulation plus tissue work, and radiation-related deformity of the implant pocket with associated soft tissue revision.

Scope Boundaries

The "significant" threshold in the descriptor is the operative standard. Minor liposuction, isolated scar revision, or limited capsulotomy without accompanying soft tissue excision do not clear the bar for 19380. If a limited procedure has its own defined CPT code (such as a scar revision), the more specific code governs. For autologous cases, liposuction alone to reduce flap fullness may qualify as part of a 19380 procedure when it is performed as the primary revisional technique and substantially alters the breast mound; the operative note should reflect this explicitly.

Provider and Setting Context

Performed exclusively by plastic and reconstructive surgeons. Typically billed in the hospital outpatient (OPPS) or ambulatory surgery center (ASC) setting under general anesthesia. 19380 carries an ASC payment indicator confirming it is on the covered ASC surgical procedure list, with payment based on OPPS relative payment weight. Hospital outpatient claims are paid through a comprehensive APC.

Code Differentiation Table

The critical differentiator: the two-part test for implant-based revision. Auditors specifically look for whether soft tissue excision is documented alongside capsular work. When only the capsule is addressed, 19370 or 19371 is the correct choice regardless of capsular revision complexity.

Decision flowchart for implant-based breast revision:

flowchart TD
    A[Implant-based reconstruction revision] --> B{Capsular revision performed?}
    B -- No --> C[Report other appropriate code]
    B -- Yes --> D{Significant soft tissue excision also performed?}
    D -- No --> E[19370 or 19371\nCapsule-only revision]
    D -- Yes --> F[19380\nCombined capsular + soft tissue revision]

Billing and Modifier Rules

Modifier Usage

Units and MUE

MUE for 19380 is 1. One unit covers the entire revision of one breast. For bilateral revisions, the service is reported as 19380-50 (one line) or as two separate lines with -RT and -LT, depending on payer instructions. Medicare and most MACs have a preference; verify before submission.

Bundling Alerts

19370 and 19371 bundle into 19380 when performed on the same breast at the same session. Capsular work performed as part of a combined capsule and soft tissue revision is a component of 19380; do not separately report capsule-only codes alongside it. Verification against current CMS NCCI PTP tables is required before submission, as NCCI edits are updated quarterly.

19342 (implant replacement) and fat grafting codes 15771 and 15772 may be separately reportable when performed as distinct additional procedures, but NCCI PTP edit verification is required for each pairing. 19350 (nipple/areola reconstruction) is not bundled with 19380 and may be reported on the same date with modifier -51.

Global Period

19380 carries a 90-day global period (major surgery). Pre-operative visits on the day before or day of surgery and post-operative follow-up within 90 days are included in the global payment. Modifiers -58, -78, or -79 are the mechanism to obtain separate payment for related or unrelated surgical procedures within the global window.

Documentation Essentials

Required Elements

The operative report must establish:

• Prior reconstruction type and history: Document the original reconstruction (autologous flap type, e.g., DIEP, TRAM, latissimus dorsi; or implant type and placement) including approximate date and any intervening procedures.
• Clinical indication for revision: Specific findings, measured or graded where applicable (Baker grade for capsular contracture, documented asymmetry, imaging findings for implant malposition, photographic documentation of contour deformity).
• Procedure-specific description for autologous cases: Volume or extent of tissue excised and/or specific description of flap re-advancement or re-inset. Vague terms such as "revision of breast" are insufficient. The record must support that the work was "significant."
• Procedure-specific description for implant-based cases: Separate documentation of both the capsular revision component (what was done to the capsule) and the soft tissue excision component (what tissue was excised, from where). Both must be present and explicit.
• Laterality: Left, right, or bilateral; essential for modifier application and audit compliance.
• WHCRA context: If reconstruction follows mastectomy for cancer, document the mastectomy history and the sequence of reconstruction. This establishes the reconstructive (not cosmetic) medical necessity basis.

Audit Red Flags

Auditors flag 19380 claims when:

• The operative report documents capsular work without separate documentation of soft tissue excision in an implant-based case, indicating 19370 or 19371 is the more appropriate code.
• 19370 or 19371 is reported alongside 19380 for the same breast on the same date, indicating a likely NCCI edit violation.
• The claim falls within the 90-day global period of the original reconstruction without a modifier, triggering automatic bundling denial.
• No preoperative photographs are on file when the payer or MAC requires them to support medical necessity for aesthetic revision.
• The diagnosis code reflects a cosmetic rather than reconstructive context when mastectomy history exists in the record.

Medical Necessity

For Medicare, breast reconstruction revision following mastectomy is classified as reconstructive, not cosmetic. The documentation must establish that the reconstruction follows treatment for disease, trauma, or congenital deformity. MAC-level LCDs govern coverage criteria; no national NCD covers breast reconstruction. Coders should verify the active LCD applicable to their jurisdiction via the CMS Medicare Coverage Database [3].

Medicare, Commercial and Medicaid Payer Rules

Medicare

19380 is an active physician service code (PC/TC indicator 0) with a 90-day global period. The MPFS bilateral surgery indicator is 1, confirming 150% payment for bilateral procedures. Assistant surgeon payment is subject to statutory restriction (indicator 1); documentation supporting assistant surgeon necessity is required and payment is not automatic. Co-surgeons and team surgery are not permitted (indicators 0).

The code is payable in the ASC setting (on the ASC list since CY 2007, payment based on OPPS relative payment weight) and in the hospital outpatient setting through a comprehensive APC. No national NCD exists; coverage is MAC-determined via local LCDs [3].

CMS requires the medical record to support the reconstructive nature of the procedure when the original mastectomy was performed for disease treatment, consistent with the WHCRA [4].

Commercial Payers

WHCRA [4] requires that any group health plan covering mastectomy must also cover all stages of reconstruction including revision. Commercial payers may impose prior authorization requirements for revision surgery, particularly for aesthetic revision following cancer reconstruction. Diagnosis code selection matters: submitting a cosmetic diagnosis when the reconstruction is post-mastectomy may trigger denial even when WHCRA mandates coverage. Use Z42.1, N65.1, or T85.44XA as appropriate to reflect the reconstructive context.

Some commercial payers impose their own documentation requirements, including preoperative photographs and detailed prior authorization documentation specifying the type of revision and its clinical necessity.

Medicaid

No state-specific guidance was available in the research document. WHCRA applies to group health plans but not to Medicaid. Medicaid coverage of breast reconstruction revision varies by state. Managed Medicaid plans may impose prior authorization requirements or limit coverage to post-mastectomy reconstruction. Verify applicable state plan and managed care plan policies before billing.

Common Denials and Prevention

Denial: Bundled into global period Without a global period modifier, any related surgical service during the 90-day post-operative window of the original reconstruction is automatically bundled by the payer's claims processing system. The claim will be denied or zero-paid. Prevention: Apply -58 for staged/planned revision, -78 for unplanned return to OR for a related complication, or -79 for an unrelated procedure. Document the modifier rationale in the record. Confirm that the original procedure date and the revision date are submitted correctly to enable global period calculation.

Denial: Upcoding / Code substitution to 19370 or 19371 Payers and RAC auditors reviewing implant-based revision claims will downcode 19380 to 19370 or 19371 when the operative report does not document soft tissue excision alongside capsular revision. Prevention: The operative report must explicitly document the soft tissue excision component as a distinct element of the procedure, separate from the capsular work. If only capsular revision was performed, use 19370 or 19371 prospectively to avoid recoupment.

Denial: Insufficient documentation of significance Vague operative language ("revised breast," "improved contour") without quantifying tissue removal or detailing the extent of flap work fails medical necessity review. Prevention: The operative note should document the volume of tissue excised or the specific anatomical work performed on the flap (re-inset to new position, amount advanced, technique). For implant cases, describe the capsular findings and the specific soft tissue excised.

Denial: Missing bilateral modifier Bilateral revision billed without modifier -50 (or -LT/-RT) results in payment for only one side at standard rate, not the 150% bilateral adjustment. Prevention: When both reconstructed breasts are revised in the same session, confirm modifier -50 or paired -LT/-RT is appended. Verify MAC and payer preference for -50 versus -LT/-RT to avoid secondary billing edits.

Denial: NCCI bundling of capsule codes Reporting 19370 or 19371 alongside 19380 for the same breast on the same date will trigger an NCCI PTP edit denial. Prevention: When 19380 is supported by the documentation, do not separately report 19370 or 19371 for the same breast. Capsular work is a component of 19380 in combined procedures. Appeals based on modifier -59 or XS for distinct procedures are unlikely to succeed when the capsular work is part of the same revision.

Coding Scenarios

Scenario 1: Autologous flap revision, outside global period

A patient with a DIEP flap reconstruction performed 8 months ago presents with excess flap fullness in the lower pole and asymmetry relative to the contralateral breast. The surgeon excises a wedge of excess flap tissue and re-advances the inferior flap margin to improve shape and projection.

Correct coding: 19380 + N65.1 (disproportion of reconstructed breast). No global modifier required; 8 months is outside the 90-day global period of the original reconstruction.

Why: Significant tissue excision combined with flap re-advancement meets both autologous revision elements in the 19380 descriptor. N65.1 reflects the documented asymmetry indication.

Scenario 2: Implant-based revision with capsular contracture, staged during global period

A patient underwent tissue expander-to-implant exchange (19342) 6 weeks ago. At that time, a second-stage revision of lower pole contour was planned and documented in the consent and operative report. The surgeon returns to OR for significant capsulotomy and removal of inferior capsular tissue combined with excision of excess lower pole skin.

Correct coding: 19380-58 + Z42.1 (encounter for breast reconstruction following mastectomy).

Why: The procedure falls within the 90-day global of 19342 and was planned, requiring modifier -58 to allow separate payment. Both the capsular revision and soft tissue excision are documented, satisfying the implant-based pathway for 19380.

Scenario 3: Capsular contracture, capsule only — correct downselection

A patient with implant-based reconstruction presents with Baker Grade III capsular contracture. The surgeon performs partial capsulectomy to release the contracture. No skin or soft tissue is excised.

Correct coding: 19370 + T85.44XA (capsular contracture of breast implant, initial encounter).

Why: Only capsular revision was performed. The 19380 parenthetical requires BOTH significant capsular revision AND soft tissue excision for implant-based cases. Reporting 19380 here would constitute upcoding; 19370 correctly captures the capsule-only work.

Scenario 4: Bilateral autologous revision with fat grafting

A patient with bilateral latissimus dorsi flap reconstruction presents with bilateral contour depressions on the superior poles. The surgeon re-advances the flap bilaterally to correct shape and separately performs 45 cc of autologous fat grafting to the superior pole depressions.

Correct coding: 19380-50 + 15771-51 + N65.1. Alternatively, 19380-RT and 19380-LT per MAC preference.

Why: Bilateral flap re-advancement qualifies for 19380-50 with the 150% bilateral adjustment. Fat grafting is a distinct additional procedure reportable separately with -51; verify current NCCI PTP edits between 19380 and 15771 before submission.

Related Codes

• 19370 (CPT) — Revision of peri-implant capsule including capsulotomy/capsulorrhaphy/partial capsulectomy; use when capsular revision is performed without accompanying significant soft tissue excision
• 19371 (CPT) — Complete peri-implant capsulectomy; use for total capsule removal without soft tissue excision component
• 19342 (CPT) — Implant insertion or replacement on separate day from mastectomy; may be separately reportable when implant is replaced during revision
• 19350 (CPT) — Nipple/areola reconstruction; distinct from breast mound revision, not bundled with 19380
• 19357 (CPT) — Tissue expander placement in breast reconstruction; applicable if revision involves expander re-placement
• 15771 (CPT) — Autologous fat grafting to trunk/breasts, 50 cc or less; commonly performed with 19380 for contour refinement
• 15772 (CPT) — Autologous fat grafting, each additional 50 cc; add-on to 15771 when volume exceeds 50 cc
• Z42.1 (ICD-10-CM) — Encounter for breast reconstruction following mastectomy; primary diagnosis for planned revision visits
• N65.1 (ICD-10-CM) — Disproportion of reconstructed breast; diagnosis when asymmetry is the documented indication
• T85.44XA (ICD-10-CM) — Capsular contracture of breast implant, initial encounter; diagnosis for implant-based revision due to contracture

Sources {#sources}

1. AMA CPT 2025 Professional Edition — Official CPT 19380 descriptor, parenthetical guidance, and codebook notes for the Repair and/or Reconstruction of the Breast section
2. CMS Physician Fee Schedule — Global days, bilateral surgery indicator, assistant surgeon indicator, co-surgeon and team surgery indicators, MUE, and ASC payment indicator for 19380
3. CMS Medicare Coverage Database — MAC LCDs governing breast reconstruction coverage criteria; no national NCD exists for this service
4. Women's Health and Cancer Rights Act (WHCRA) — CMS CCIIO — Federal mandate requiring group health plan coverage of all reconstruction stages including revision following mastectomy
5. CMS National Correct Coding Initiative (NCCI) — PTP edits and MUE values governing bundling relationships between 19380 and related capsule codes; quarterly updates require ongoing verification