Part 2: CPT Education - Breast Implant Reconstruction Using A Tissue Expander

Beth Martilik,​ MA, RHIA, CDIP, CCS
Assistant Director of Education
AHIMA Approved ICD‑10 Trainer and Ambassador

This is Part 2 of a 6-part series focusing on CPT coding of breast procedures. There are many different types of breast reconstruction procedures, each having potential stumbling-blocks for coders. This series will address several of the more confusing topics. Part 2 focuses on the use of tissue expanders in breast reconstruction.

Tissue expanders are used when there is insufficient skin left on the chest following a mastectomy to provide adequate coverage of a breast implant. Tissue expanders are inflatable breast implants that have silicone outer shells and either an internal valve or external port to allow for saline fluid injections that stretch the skin over time. Once the skin has been stretched sufficiently, the tissue expander is removed and replaced with a permanent breast implant. This type of breast reconstruction is known as staged reconstruction.

 

The initial insertion of a tissue expander is assigned to CPT code 19357.

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19357

Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion

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Part 3 of this series will discuss the various coding options for insertion of a breast implant.

 

References:
CPT Assistant, August 2005, Volume 15, Issue 8, Page 1-3
https://www.youtube.com/watch?v=J9B23xnIoTw (animation of tissue expander insertion)

 

The information contained in this series is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.