How To Use CPT Code 19330

CPT code 19330 describes the removal of ruptured breast implant material, including the contents such as saline or silicone gel. 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 19330?

CPT 19330 is used to describe the removal of ruptured breast implant material, including the contents such as saline or silicone gel. This code is specifically for cases where there is a rupture of the breast implant. It should not be reported for the removal of a ruptured tissue expander. If a ruptured tissue expander is removed with the placement of a new breast implant, CPT code 11970 should be used. If the ruptured tissue expander is removed without replacement, CPT code 11971 should be used. If a new breast implant is placed during the same operative session, CPT code 19342 should be used.

2. Official Description

The official description of CPT code 19330 is: ‘Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel).’ It is important to note that this code should not be reported for the removal of a ruptured tissue expander.

3. Procedure

When performing CPT 19330, the physician begins by appropriately prepping and anesthetizing the patient. An incision is then made over the breast to access the ruptured implant. The physician carefully removes the implant material, including any contents such as saline or silicone gel. The procedure aims to completely remove the ruptured implant and its contents to address the rupture and prevent any further complications.

4. Qualifying circumstances

CPT 19330 is used in cases where there is a rupture of a breast implant. It is important to note that this code should not be reported for the removal of a ruptured tissue expander. The procedure should be performed by a qualified healthcare professional who is experienced in performing breast implant removal surgeries.

5. When to use CPT code 19330

CPT code 19330 should be used when there is a documented rupture of a breast implant and the physician performs the removal of the ruptured implant material, including the contents such as saline or silicone gel. It is important to accurately document the rupture and the need for removal in the patient’s medical record to support the use of this code.

6. Documentation requirements

To support a claim for CPT 19330, the following documentation should be included:

• Documentation of the rupture of the breast implant
• Documentation of the need for removal of the ruptured implant
• Details of the procedure performed, including the incision made and the removal of the implant material and contents
• Any additional procedures performed during the same operative session, if applicable
• Signature of the performing physician

7. Billing guidelines

When billing for CPT 19330, ensure that the procedure performed is the removal of a ruptured breast implant, including the implant contents. It is important to accurately document the rupture and the need for removal in the patient’s medical record. CPT code 19330 should not be reported for the removal of a ruptured tissue expander. If a new breast implant is placed during the same operative session, CPT code 19342 should be used. It is important to follow the specific guidelines provided by the payer and ensure accurate coding and documentation to support the claim.

8. Historical information

CPT code 19330 was added to the Current Procedural Terminology system on January 1, 1990. The code was later updated on January 1, 2021, with a change in the description to ‘Removal of mammary implant material.’

9. Similar codes to CPT 19330

There are several similar codes to CPT 19330 that are used for different procedures related to breast repair and reconstruction. These codes include:

• CPT 19316: Removal of breast implant material
• CPT 19340: Immediate insertion of breast prosthesis following mastopexy, mastectomy, or in reconstruction
• CPT 19342: Breast reconstruction with latissimus dorsi flap, without prosthetic implant
• CPT 19350: Nipple/areola reconstruction
• CPT 19396: Unlisted procedure, breast

9. Examples

1. A patient presents with a ruptured silicone breast implant. The physician performs CPT 19330 to remove the ruptured implant material, including the silicone gel.
2. During a routine follow-up examination, a patient is found to have a ruptured saline breast implant. The physician schedules the patient for CPT 19330 to remove the ruptured implant and replace it with a new implant.
3. A patient with a history of breast augmentation experiences a rupture of their saline breast implant. The physician performs CPT 19330 to remove the ruptured implant and discusses the option of implant replacement with the patient.
4. Following a mastectomy and breast reconstruction, a patient experiences a rupture of their breast implant. The physician performs CPT 19330 to remove the ruptured implant material and discusses the possibility of a revision surgery with the patient.
5. A patient presents with a ruptured silicone breast implant and requests its removal. The physician performs CPT 19330 to remove the ruptured implant material and discusses the patient’s options for further breast reconstruction.
6. During a routine mammogram, a patient is found to have a ruptured saline breast implant. The physician schedules the patient for CPT 19330 to remove the ruptured implant and discusses the possibility of implant replacement.
7. A patient with a history of breast augmentation experiences a rupture of their silicone breast implant. The physician performs CPT 19330 to remove the ruptured implant material and discusses the patient’s options for implant replacement or alternative breast reconstruction procedures.
8. Following a breast augmentation surgery, a patient presents with a ruptured saline breast implant. The physician performs CPT 19330 to remove the ruptured implant and discusses the patient’s options for implant replacement or revision surgery.
9. A patient with a history of breast reconstruction experiences a rupture of their breast implant. The physician performs CPT 19330 to remove the ruptured implant material and discusses the patient’s options for revision surgery or alternative breast reconstruction procedures.