CPT Codes 19342, 11970, & 19370: Review the New Reporting Guidance for Breast Implant Scenarios from AHA

CPT Codes 19342, 11970, & 19370: Review the New Reporting Guidance for Breast Implant Scenarios from AHA

For the Current Procedural Terminology (CPT®) 2021 code set, AHA revised or deleted a significant number of codes. This is especially true in the Breast subsection of the Integumentary System section. In addition, AHA added new introductory guidelines to the Repair and/or Reconstruction subsection. There were also numerous instructional parenthetical notes, for CPT codes 19342, 11970 and 19370. AHA made these changes to reflect current practice, simplify terms, and clarify physician work.

Examples of Proper Coding

However, coders still struggle with using these codes for some coding scenarios, such as stage 2 reconstructions. We refer to replacement of a tissue expander with a permanent implant as a stage 2 reconstructions. Based on updated CPT guidelines for 2021, the AHA updated their previous recommendations. This specifically applies to coding tissue expander replacements with permanent breast implants. Let’s look at the previous advice and the new current advice.

Coding Clinic for HCPCS 4Q 2020 pg. 1 instructed coders to report code 19342, Insertion or replacement of breast implant on separate day from mastectomy, when the tissue expander is replaced with permanent implants and significant (more than minor) adjustments are made to the capsule (AHIMA, 2021).

Coding Clinic for HCPCS 1Q 2021 pg. 11 issued a correction to the previous advice with an effective date of March 17, 2021, instructing coders to now assign codes 11970, Replacement of tissue expander with permanent implant, and 19370, Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy, to capture the replacement of a tissue expander with implant and capsulorrhaphy (AHIMA, 2021). The article also warned of an NCCI edit that prevents the reporting of CPT code 11970 with code 19370.

Based on the current updated references from the AHA and the current NCCI edit, coders should use code 19370 to report when a providers replaces a tissue expander with permanent implants. This also applies when providers make significant adjustments to the capsule. We remind coders that if only minor revisions are made to the capsule, then they should still report code 11970 alone for stage 2 reconstruction.

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The YES Auditing Team co-authored this article.