Summary & Overview
CPT 19316: Mastopexy with Implant (Breast Lift and Augmentation)
CPT code 19316 covers mastopexy procedures that include breast augmentation with an implant, a key surgical intervention in plastic surgery for patients requiring breast reconstruction or enhancement. This code is nationally recognized and utilized in both ambulatory surgical centers and hospital outpatient settings, reflecting its importance in the clinical management of breast conditions. The procedure is relevant for patients with a range of diagnoses, including various malignant neoplasms and carcinomas of the breast, and is often performed as part of comprehensive cancer care or reconstructive surgery.
Major payers such as Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare provide coverage for services billed under CPT code 19316. Readers will gain insight into payer coverage, clinical indications, and typical sites of service for this procedure. The publication also addresses associated billing modifiers, relevant taxonomies, and ICD-10 diagnoses, offering a comprehensive overview of policy updates and benchmarks for mastopexy with implant. This summary is designed to inform healthcare professionals, billing specialists, and policy analysts about the national landscape for CPT code 19316 and its role in plastic surgery.
CPT Code Overview
CPT code 19316 describes a mastopexy procedure, which involves the surgical lifting and reshaping of the breast. This code specifically includes augmentation with an implant when performed. The service falls under plastic surgery and is typically provided in an ambulatory surgical center or hospital outpatient setting (Place of Service 24 or 22). Mastopexy with implant is commonly performed to address breast shape and volume concerns, often following mastectomy or for reconstructive purposes.
Clinical & Coding Specifications
Clinical Context
A typical patient scenario involves an individual diagnosed with a malignant or non-malignant neoplasm of the breast, such as basal cell carcinoma or squamous cell carcinoma. The patient may require surgical intervention to remove the tumor and restore breast contour. The procedure described by CPT code 19316—mastopexy including augmentation with implant—is performed to lift and reshape the breast, often following tumor excision, and may include placement of an implant for volume restoration. This surgery is commonly performed in an ambulatory surgical center or hospital outpatient setting. The clinical workflow includes preoperative assessment, surgical planning, tumor excision if indicated, mastopexy with implant placement, and postoperative care.
Coding Specifications
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Modifier
51: Used when multiple procedures are performed during the same operative session. Indicates that19316is one of several procedures. -
Modifier
59: Used to denote a distinct procedural service, indicating that19316is separate from other procedures performed on the same day.
| Modifier Code | Description |
|---|---|
51 | Multiple Procedures |
59 | Distinct Procedural Service |
Provider Taxonomies:
| Taxonomy Code | Specialty Name |
|---|---|
208200000X | Plastic Surgery |
2086S0122X | Surgery of the Hand (Plastic Surgery) |
2086X0206X | Surgical Critical Care (Plastic Surgery) |
- Plastic Surgery: Specialists performing reconstructive and cosmetic breast procedures.
- Surgery of the Hand (Plastic Surgery): May be involved if complex reconstruction is required.
- Surgical Critical Care (Plastic Surgery): Manages perioperative care for complex cases.
Related Diagnoses
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C44.511– Basal cell carcinoma of skin of breast- Relevant for patients requiring breast surgery due to skin cancer.
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C44.521– Squamous cell carcinoma of skin of breast- Indicates squamous cell carcinoma necessitating surgical excision and reconstruction.
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C44.591– Other specified malignant neoplasm of skin of breast- Used for other malignant skin neoplasms requiring breast surgery.
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C50.011– Malignant neoplasm of nipple and areola, right female breast- Indicates cancer in the nipple/areola region, often requiring surgical intervention.
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C50.012– Malignant neoplasm of nipple and areola, left female breast- Same as above, but for the left breast.
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C50.021– Malignant neoplasm of nipple and areola, right male breast- Relevant for male patients with cancer in the nipple/areola.
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C50.022– Malignant neoplasm of nipple and areola, left male breast- Same as above, for the left breast.
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C50.111– Malignant neoplasm of central portion of right female breast- Indicates central breast cancer requiring surgical management.
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C50.112– Malignant neoplasm of central portion of left female breast- Same as above, for the left breast.
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C50.121– Malignant neoplasm of central portion of right male breast- Central breast cancer in male patients.
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C50.122– Malignant neoplasm of central portion of left male breast- Same as above, for the left breast.
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C50.211– Malignant neoplasm of upper‑inner quadrant of right female breast- Cancer located in the upper-inner quadrant, requiring surgical intervention.
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C50.212– Malignant neoplasm of upper‑inner quadrant of left female breast- Same as above, for the left breast.
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C50.221– Malignant neoplasm of upper‑inner quadrant of right male breast- Cancer in the upper-inner quadrant of the right male breast.
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C50.222– Malignant neoplasm of upper‑inner quadrant of left male breast- Same as above, for the left breast.
These diagnoses are clinically relevant as they represent conditions for which mastopexy with implant placement may be indicated, either for oncologic resection or reconstructive purposes.
Related CPT Codes
19350– Correction of Hagman deformity
Clinical Relationship:
- CPT code
19350may be performed in conjunction with or as an alternative to19316when correcting breast deformities, such as those resulting from previous surgery or congenital anomalies. Both codes address breast reconstruction, but19316specifically includes mastopexy with implant placement, while19350focuses on correction of Hagman deformity. These codes are not typically billed together unless clinically justified.
National Reimbursement Benchmarks
For CPT code 19316, the national mean rate for Medicare is $742.83, while the average commercial mean rate (BUCA) is $974.43. Commercial payers such as UnitedHealth Group and Cigna have notably higher mean rates, with UnitedHealth Group at $1,331.30 and Cigna at $1,288.90. Blue Cross Blue Shield and Aetna are closer to the BUCA average, at $936.59 and $688.86 respectively.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Aetna has the tightest range at $424.62, while UnitedHealth Group shows the widest spread at $799.00. Medicare's range is also relatively narrow at $62.00, indicating less variability in rates compared to commercial payers.
The table and chart below present the full breakdown of national benchmarks for each payer, including mean rates and percentile values.
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