How To Use CPT Code 19328

CPT code 19328 describes the removal of a previously placed breast implant. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 19328?

CPT code 19328 is used to describe the removal of a previously placed breast implant. This procedure involves opening an old surgical scar, removing the implant, and then closing the incision. It is important to note that CPT 19328 should not be reported for the removal of a tissue expander or in conjunction with CPT 19370. For the removal of a tissue expander with the placement of a breast implant, CPT code 11970 should be used. If the tissue expander is removed without replacement, CPT code 11971 is appropriate.

2. Official Description

The official description of CPT code 19328 is: ‘Removal of intact breast implant.’

3. Procedure

The procedure for CPT code 19328 involves the following steps:

1. The physician opens an old surgical scar.
2. The previously placed breast implant is carefully removed.
3. The incision is closed.

4. Qualifying circumstances

CPT code 19328 is used when a previously placed breast implant needs to be removed. This may be necessary for various reasons, such as implant rupture, capsular contracture, infection, or patient preference. It is important to note that CPT 19328 should not be used for the removal of a tissue expander or in conjunction with CPT 19370.

5. When to use CPT code 19328

CPT code 19328 should be used when a previously placed breast implant needs to be removed. It is important to ensure that the procedure performed aligns with the description of the code. If the removal involves a tissue expander or is performed in conjunction with another procedure, different CPT codes should be used.

6. Documentation requirements

To support a claim for CPT code 19328, the following documentation should be included:

• Patient’s medical history and indication for implant removal
• Description of the procedure performed, including the opening of the old surgical scar, removal of the implant, and closure of the incision
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the physician performing the procedure

7. Billing guidelines

When billing for CPT code 19328, it is important to ensure that the procedure performed aligns with the code description. CPT 19328 should not be reported for the removal of a tissue expander or in conjunction with CPT 19370. If the removal involves a tissue expander with the placement of a breast implant, CPT code 11970 should be used. If the tissue expander is removed without replacement, CPT code 11971 is appropriate.

8. Historical information

CPT code 19328, ‘Removal of intact breast implant,’ was added to the Current Procedural Terminology system on January 1, 1990. The code was last updated on January 1, 2021, with a change in the code description to specify ‘mammary implant’ instead of ‘breast implant.’

9. Examples

Here are some examples of cases where CPT code 19328 would be appropriate:

1. A patient with a history of breast augmentation decides to have their implants removed.
2. An individual experiences complications, such as implant rupture or capsular contracture, and requires the removal of their breast implant.
3. A patient decides to undergo breast reconstruction using a different technique and needs their previous breast implant removed.
4. An infection develops around a breast implant, necessitating its removal.
5. A patient decides to have their breast implants removed due to personal preference or lifestyle changes.
6. A breast implant is found to be causing discomfort or pain, and the patient opts for its removal.
7. A patient with a history of breast cancer chooses to have their breast implant removed after completing their cancer treatment.
8. An individual experiences a change in breast size or shape and decides to have their breast implant removed.
9. A patient decides to have their breast implant removed and replaced with a different size or type of implant.
10. An individual decides to have their breast implant removed as part of a breast revision surgery.