Implant-Based Breast Reconstruction
1934019342wRVU: 10.22 — Insertion or replacement of breast implant on separate day from mastectomy (10.22 wRVU, 90-day global) — use for delayed or delayed-immediate reconstruction; for straightforward expander exchange, use 11970 instead19357wRVU: 14.47 — Tissue expander placement in breast reconstruction, including subsequent expansion(s) (14.47 wRVU, 90-day global)11970wRVU: 7.3 — Replacement of tissue expander with permanent implant (7.30 wRVU, 90-day global) — default code for stage-2 expander exchange; use 19342 only when extensive capsular work is concurrently performed15777wRVU: 3.56 — Biologic implant (acellular dermal matrix) for soft tissue reinforcement (3.56 wRVU, add-on) — list separately in addition to primary reconstruction code when ADM is placed
Status post mastectomy for [breast cancer / BRCA prophylaxis]
Same
[Immediate / delayed] implant-based breast reconstruction [with / without] acellular dermal matrix (ADM), [right / left / bilateral]
[Attending name], MD
[Resident/Fellow/PA name]
General endotracheal
Patient with [breast cancer / BRCA mutation] status post [skin-sparing / nipple-sparing] mastectomy by the breast surgery team. Patient desires [direct-to-implant / tissue expander] reconstruction. Body habitus and skin envelope [adequate / limited]. Prior radiation [history / none]. Implant type, size, and position discussed. Risks including infection, implant failure, capsular contracture, rippling, and asymmetry discussed. Patient Decision Checklist reviewed and completed. Consent obtained.
Skin flap perfusion [adequate / limited]. [Nipple-areolar complex perfusion confirmed with SPY/ICG angiography.] Mastectomy pocket dimensions [X x Y] cm. Selected implant: [Mentor / Motiva / Allergan Natrelle smooth] [round / shaped] [X] cc smooth silicone gel implant, lot #[XXX].
The patient was positioned supine and the breast was prepped and draped in sterile fashion in coordination with the breast surgery team following mastectomy. [Pocket irrigation with triple antibiotic solution (vancomycin, cefazolin, gentamicin) performed.]
The pectoralis major muscle was elevated off the chest wall from its inferior and medial border using electrocautery. [An acellular dermal matrix (ADM) [Alloderm / Flex HD], sized [X x Y] cm, was sutured to the inferior border of the pectoralis using 2-0 Vicryl, creating a dual-plane pocket with ADM forming the inferior sling.] The implant pocket was irrigated again with antibiotic solution.
A [X]-cc [manufacturer] silicone gel implant (lot #[XXX]) was inserted into the pocket in a no-touch technique using a Keller funnel. The implant was positioned [centrally / appropriately]. The pectoralis and ADM were closed over the implant with [running 2-0 Vicryl]. The patient was raised to 75–90 degrees for intraoperative assessment. Implant position [symmetric / satisfactory]. Skin closed in layers with 3-0 Monocryl deep dermis and 4-0 Monocryl subcuticular. Steri-strips applied.
[For tissue expander:] A [X]-cc expander was placed. Filled intraoperatively to [X] cc [or to patient tolerance]. Plan for serial expansion in clinic.
Patient tolerated the procedure well.
None
None
Minimal
[One / two] [10-Fr] JP drains placed in the implant pocket
Patient taken to PACU in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Status post mastectomy for [breast cancer / BRCA prophylaxis]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Immediate / delayed] implant-based breast reconstruction [with ADM], [right / left / bilateral]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [breast cancer / BRCA mutation], status post [skin-sparing / nipple-sparing] mastectomy. Patient desires [direct-to-implant / tissue expander] reconstruction. [No prior radiation.] Implant type, size, and position discussed. Patient Decision Checklist reviewed. Risks including infection, implant failure, capsular contracture, and asymmetry were discussed. Informed consent obtained.
FINDINGS: Skin flap perfusion adequate [confirmed with SPY/ICG angiography]. Mastectomy pocket dimensions *** × *** cm. Selected implant: [Mentor / Motiva / Allergan Natrelle] *** cc [round / shaped] smooth silicone gel, lot #***.
DESCRIPTION OF PROCEDURE:
Patient positioned supine. Breast prepped in sterile fashion in coordination with breast surgery team following mastectomy. Pocket irrigated with triple antibiotic solution (vancomycin, cefazolin, gentamicin). Pectoralis major elevated off the chest wall from its inferior and medial border with electrocautery. [ADM (Alloderm / Flex HD), *** × *** cm, sutured to inferior pectoralis border with 2-0 Vicryl, creating dual-plane pocket with ADM inferior sling.] Pocket re-irrigated. A ***-cc [manufacturer] silicone gel implant (lot #***) inserted in no-touch technique via Keller funnel. Pectoralis [and ADM] closed over implant with running 2-0 Vicryl. Patient raised to 75–90 degrees. Implant position symmetric and satisfactory. Skin closed with 3-0 Monocryl deep dermis and 4-0 Monocryl subcuticular. Steri-strips applied. JP drains placed. Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: None
COMPLICATIONS: None
DRAINS: [One / two] 10-Fr JP drains in implant pocket
DISPOSITION: Patient taken to PACU in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Tissue expander (two-stage)
Stage 1: expander placement (CPT 19357, 14.47 wRVU). Stage 2: exchange to permanent implant — default code is CPT 11970 (7.30 wRVU); use CPT 19342 only when extensive capsular work (capsulectomy, multiple radial capsulotomies) is also performed. Document expander size, initial fill volume, and tissue quality at exchange.
Pre-pectoral reconstruction
Implant above pectoralis muscle with complete ADM wrap. Document muscle preservation, ADM dimensions, and complete anterior (and posterior if used) pocket coverage. Bill +15777 for ADM.
With nipple reconstruction
CPT 19350. Document technique (C-V flap, skate flap, star flap), areolar tattooing plan. Areolar tattooing performed within the 90-day global period is bundled and cannot be billed separately.
Charting Tips
- Document implant manufacturer, model, lot number, and size for National Breast Implant Registry (NBIR) tracking
- Per FDA 2021 requirement, confirm completion of the Patient Decision Checklist (PDC) before implant placement and document this in the preoperative note
- State ADM brand, size, and fixation technique; document +15777 add-on when ADM is used
- Note ICG/SPY perfusion assessment of skin flaps if performed
- No-touch implant technique and antibiotic irrigation protocol
- Intraoperative position check (75–90 degrees) and symmetry assessment
- Prior radiation significantly increases capsular contracture and implant loss risk. Document radiation history explicitly.
Billing Tips
- 19340 (immediate implant same day as mastectomy, 10.22 wRVU, 90-day global) vs 19342 (insertion or replacement of breast implant on separate day from mastectomy, 10.22 wRVU, 90-day global): timing determines the code, not implant type.
- 19357 (tissue expander placement, 14.47 wRVU, 90-day global) is used for staged reconstruction. The standard stage-2 expander-to-implant exchange is CPT 11970 (replacement of tissue expander with permanent implant, 7.30 wRVU, 90-day global). Use 19342 only when extensive capsular work is also performed at the exchange (e.g., formal capsulectomy, multiple radial capsulotomies) — 19342 for a straightforward exchange will be denied or downcoded.
- Global period is 90 days for all breast reconstruction codes. Coordinate post-op billing with the mastectomy surgeon.
- Bilateral reconstruction: for Medicare, append modifier -50 to a single line item (1 unit); reimbursement is 150% of the unilateral fee schedule amount. Some commercial payers accept -RT/-LT on two separate lines — verify payer policy before submitting.
- Document whether reconstruction is immediate (same operative session as mastectomy) or delayed. This is critical for code selection and payer authorization.
- Oncoplastic or symmetry procedures on the contralateral breast (mastopexy 19316, reduction 19318, augmentation 19325) are separately billable and covered under the Women's Health and Cancer Rights Act (WHCRA) of 1998. Document the symmetry work separately.
- When ADM is used for soft tissue reinforcement (inferior sling or complete prepectoral wrap), add CPT +15777 (biologic implant for soft tissue reinforcement, 3.56 wRVU, add-on) listed in addition to the primary reconstruction code (19340, 19342, or 19357).
- HCPCS device codes are facility-billed, not surgeon-billed. L8600 is for a silicone breast implant; tissue expanders are billed by facilities as C1789. Surgeons do not bill implant device codes on the professional claim.
General coding reference. Verify with your institution’s billing department before submitting claims.