February 18, 2016

Question:
We have a patient who had bilateral mastectomies and had permanent implants placed several years ago. She now wants smaller implants. I have to get precertification for this procedure and am looking at the CPT codes 19328 (implant removal) and 19325 (breast augmentation) for the procedure. Would that be right?

Answer:
Actually, it is best to report 19340 (Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction) for this procedure since the patient has had prior mastectomies. Precertification is important as many payers will not pay for the implant exchange without an associated medical condition (e.g., painful capsular contracture).

*This response is based on the best information available as of 02/18/16.