Summary & Overview
CPT 19340: Removal of Intact Breast Implant with Internal Capsulotomy
CPT code 19340 is a critical billing code for the removal of an intact breast implant, including internal capsulotomy when performed, as part of reconstructive breast surgery. This procedure is frequently required for patients with medical indications such as malignancy or complications related to breast implants. The code is typically used in hospital outpatient settings and is billed in addition to the primary surgical procedure.
Major national payers covering this service include Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare. Understanding the nuances of 19340 is important for providers, payers, and policy analysts, as it impacts reimbursement, coding accuracy, and compliance with clinical guidelines. The publication provides insights into payer coverage, common billing practices, and the clinical context for when this procedure is performed.
Readers will gain a comprehensive overview of benchmarks, policy updates, and the clinical landscape surrounding breast implant removal. The article also highlights related codes and modifiers, offering clarity on how 19340 fits within broader reconstructive breast surgery billing and coding practices. This information is valuable for stakeholders seeking to stay informed about evolving standards in surgical oncology and plastic surgery.
CPT Code Overview
CPT code 19340 represents the removal of an intact breast implant, including internal capsulotomy when performed. This procedure is typically part of reconstructive breast surgery and is often conducted in a hospital outpatient setting, most commonly at place of service 22. The code is listed separately in addition to the primary procedure, reflecting its role as an adjunct to more comprehensive surgical interventions. This service is essential for patients requiring implant removal due to medical necessity, such as complications or oncologic indications.
Clinical & Coding Specifications
Clinical Context
A typical patient scenario involves a patient who previously underwent breast reconstruction or augmentation with an implant, often following treatment for breast cancer or other breast malignancies. The patient now requires removal of an intact breast implant, which may be indicated due to complications such as capsular contracture, implant rupture, infection, or recurrence of malignancy. The procedure includes an internal capsulotomy when performed. The clinical workflow generally involves preoperative assessment, imaging, surgical planning, and coordination with oncology or plastic surgery teams. The service is most commonly performed in a hospital outpatient setting, such as Place of Service 22.
Coding Specifications
| Modifier Code | Description | When to Use |
|---|---|---|
50 | Bilateral Procedure | When the procedure is performed on both breasts during the same operative session. |
RT | Right Side | When the procedure is performed on the right breast. |
LT | Left Side | When the procedure is performed on the left breast. |
59 | Distinct Procedural Service | When the procedure is performed as a distinct service from other procedures on the same day. |
Associated Provider Taxonomies:
208200000X– Plastic Surgery2086S0122X– Surgical Oncology208600000X– Surgery
These taxonomies represent providers specializing in plastic surgery, surgical oncology, and general surgery, all of whom may perform this procedure.
Related Diagnoses
-
C44.511– Basal cell carcinoma of skin of breast- Relevant when implant removal is required due to skin cancer affecting the breast.
-
C44.521– Squamous cell carcinoma of skin of breast- Indicates implant removal may be necessary due to squamous cell carcinoma involvement.
-
C44.591– Other specified malignant neoplasm of skin of breast- Used when other malignant neoplasms necessitate implant removal.
-
C50.011– Malignant neoplasm of nipple and areola, right female breast- Implant removal may be part of treatment for cancer in this location.
-
C50.012– Malignant neoplasm of nipple and areola, left female breast- Indicates left-sided nipple and areola cancer requiring implant removal.
-
C50.111– Malignant neoplasm of central portion of right female breast- Implant removal may be indicated for central breast cancer.
-
C50.112– Malignant neoplasm of central portion of left female breast- Used when central left breast cancer necessitates implant removal.
-
C50.121– Malignant neoplasm of central portion of right male breast- Relevant for male patients with central breast cancer.
-
C50.122– Malignant neoplasm of central portion of left male breast- Indicates left-sided central breast cancer in males.
-
C50.211– Malignant neoplasm of upper‑inner quadrant of right female breast- Implant removal may be required for cancer in this quadrant.
-
C50.212– Malignant neoplasm of upper‑inner quadrant of left female breast- Used for upper-inner left breast cancer.
-
C50.221– Malignant neoplasm of upper‑inner quadrant of right male breast- Indicates cancer in the upper-inner quadrant of the right male breast.
-
C50.222– Malignant neoplasm of upper‑inner quadrant of left male breast- Used for upper-inner left male breast cancer.
-
C50.311– Malignant neoplasm of lower‑inner quadrant of right female breast- Implant removal may be indicated for cancer in this area.
-
C50.312– Malignant neoplasm of lower‑inner quadrant of left female breast- Used for lower-inner left breast cancer.
-
C50.321– Malignant neoplasm of lower‑inner quadrant of right male breast- Indicates lower-inner right male breast cancer.
-
C50.322– Malignant neoplasm of lower‑inner quadrant of left male breast- Used for lower-inner left male breast cancer.
-
C50.411– Malignant neoplasm of upper‑outer quadrant of right female breast- Implant removal may be required for cancer in this quadrant.
-
C50.412– Malignant neoplasm of upper‑outer quadrant of left female breast- Used for upper-outer left breast cancer.
All listed diagnoses are clinically relevant as they may necessitate removal of a breast implant as part of cancer treatment or management of associated complications.
Related CPT Codes
| CPT Code | Description | Clinical Relationship |
|---|---|---|
19357 | Breast reconstruction, immediate or delayed, with tissue expander | Often performed prior to implant placement; may precede or follow implant removal. |
19342 | Insertion or replacement of breast implant on separate day | Used when a new implant is placed after removal; may be performed in the same patient workflow. |
19325 | Breast augmentation with implant | Represents initial placement of implant; removal (19340) may follow if complications arise. |
19370 | Open periprosthetic capsulotomy, breast | Related to management of capsular contracture; may be performed with or instead of implant removal. |
19371 | Periprosthetic capsulectomy, breast | Involves removal of the capsule around the implant; may be performed in conjunction with or as an alternative to 19340. |
Codes 19357, 19342, and 19325 are commonly used in reconstructive workflows, while 19370 and 19371 address capsular issues and may be alternatives or adjuncts to 19340.
National Reimbursement Benchmarks
For CPT code 19340, national mean rates show that Medicare reimburses at $714.76, while the average commercial payer (BUCA) is higher at $1,056.84. UnitedHealth Group has the highest mean rate at $1,551.73, and Aetna and Medicare are closely aligned at the lower end of the spectrum.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Medicare exhibits the tightest range ($62.00), indicating less variability in rates. In contrast, Cigna ($828.00) and UnitedHealth Group ($992.27) have the widest ranges, reflecting greater variability in commercial reimbursement. Blue Cross Blue Shield and BUCA also show moderate dispersion, while Aetna's range is $391.33.
The table and chart below present the full breakdown of national benchmarks for each payer.
State Benchmarks
State: AK1 / 50
Alaska Benchmarks
Alaska exhibits a pronounced spread in reimbursement rates for CPT code 19340 across commercial payers, with Blue Cross Blue Shield showing a rate spread of $703.40 (from $1,474.80 at the 25th percentile to $2,178.20 at the 75th percentile), and Cigna displaying an even wider spread of $1,098.50. Aetna's rates are notably clustered, with all percentiles at $3,664.00, indicating little variability. Compared to national averages, Alaska's commercial payers consistently reimburse at much higher levels, with mean rates for Aetna, UnitedHealth Group, and Blue Cross Blue Shield far exceeding their national benchmarks. Medicare rates in Alaska are slightly below the national mean, but the difference is marginal.
The table and chart below present the full breakdown of payer-specific reimbursement rates for CPT code 19340 in Alaska, highlighting the substantial differences between payers and the elevated commercial rates relative to national figures.
Key Insights for Alaska
- Aetna is the highest paying payer for CPT 19340 in Alaska, with a mean rate of $3,173.11, while Medicare is the lowest at $700.49.
- All commercial payers in Alaska reimburse significantly above their respective national averages, with UnitedHealth Group and Blue Cross Blue Shield showing notable increases.
- The rate spread for commercial payers is substantial, indicating wide variability in reimbursement across payers.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.