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CPT 19318Surgery

Breast reduction

CPT code 19318 covers breast reduction surgery, a procedure to remove excess breast tissue, fat, and skin to reduce breast size and alleviate physical symptoms like back pain or skin irritation.

Showing rates for

National Average

Base Medicare rate

$1,072.29

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

16.03

PE RVU (NF)

14.13

MP RVU

2.99

Total RVU

33.15

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Always document grams of tissue removed from each breast in operative report. Many payers require minimum tissue removal thresholds (typically 300-600g per breast depending on body surface area) for medical necessity.
Impact: Failure to document tissue weight is the #1 cause of medical necessity denials, potentially costing the full $1072.29 reimbursement plus facility fees
Use modifier 50 for bilateral procedures rather than billing 19318 twice. Append modifier 50 to a single line item for correct Medicare payment calculation.
Impact: Incorrect bilateral billing can result in 50% underpayment ($536.15 lost) or claim rejection requiring resubmission and payment delays
Submit comprehensive pre-authorization documentation including photos (anterior, bilateral oblique, lateral views), BMI calculation, Schnur scale assessment, and 6-month conservative treatment log before surgery date.
Impact: Pre-authorization approval increases first-pass payment rate from 45% to 92% and reduces post-service appeal cycles by average 60 days
Document all symptoms with objective measurements: bra strap grooving depth in cm, intertrigo severity grading, documented physical therapy visits, and formal pain scale scores over minimum 6-month period.
Impact: Quantified symptom documentation reduces medical necessity denials by 73% and strengthens appeals with measurable improvement data
Verify patient age and medical necessity criteria. Medicare and most commercial payers deny coverage for patients under age 18 unless severe functional impairment documented, or over age 65 without compelling medical indication.
Impact: Age-related denials require extensive peer-to-peer review; verification prevents $1072.29 write-off and patient satisfaction issues

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Common denials

Medical necessity not established - insufficient documentation of conservative treatment failure or symptom severity

How to appeal: Submit detailed appeal with dated clinical notes documenting minimum 6 months conservative therapy (physical therapy, NSAIDs, supportive bras), photographic evidence of symptoms (bra grooving, rashes), formal pain assessments, and peer-reviewed literature supporting medical necessity. Include Schnur sliding scale calculation showing tissue removal meets medical criteria for patient's BSA.

Cosmetic procedure exclusion - payer determines surgery was performed primarily for aesthetic rather than functional reasons

How to appeal: Provide comprehensive documentation of functional impairment including work/activity limitations, dermatology records for chronic intertrigo, orthopedic or pain management consultations, and before/after quality of life assessments. Emphasize objective physical findings rather than patient preference for smaller breast size. Request peer-to-peer review with medical director.

Insufficient tissue removal documented - grams removed do not meet payer-specific threshold requirements

How to appeal: Submit operative report with clearly documented tissue weights and pathology report confirming measurements. Provide body surface area calculation and reference payer's specific criteria (if available) or Schnur scale demonstrating removal meets threshold. If tissue weight not documented, appeal may require surgeon affidavit estimating volume based on specimen measurements.

Billing error - incorrect use of bilateral modifier or duplicate billing resulting in claim rejection

How to appeal: Correct and resubmit claim with proper modifier 50 on single line item for bilateral procedure. Include operative report confirming bilateral reduction performed. If originally billed with RT/LT on two lines, void claims and resubmit corrected version with explanation of billing error. Request expedited processing to avoid timely filing issues.

Frequently asked questions

What is the Medicare reimbursement rate for CPT code 19318 in 2025?

The 2025 Medicare national average reimbursement for CPT 19318 is $1072.29 for both facility and non-facility settings. This is based on 33.15 total RVUs multiplied by the 2025 conversion factor of 32.3465. Actual payment may vary by geographic locality based on the Medicare Physician Fee Schedule geographic practice cost index (GPCI) adjustments.

How much tissue must be removed for insurance to cover breast reduction surgery?

Most insurers use the Schnur sliding scale, which calculates minimum tissue removal based on body surface area. Typical thresholds range from 300-800 grams per breast depending on patient size. For example, a patient with BSA of 1.75 m² typically requires removal of approximately 450-500 grams per breast. Requirements vary by payer, so verify specific criteria before surgery.

Should I bill CPT 19318 with modifier 50 or bill it twice for bilateral breast reduction?

Always use modifier 50 appended to a single line of CPT 19318 for bilateral breast reduction. Billing the code twice or using RT/LT modifiers on two separate lines is incorrect for bilateral procedures and will result in claim rejection or incorrect payment. Medicare pays 150% of the single procedure rate ($1608.44) when modifier 50 is properly applied.

What documentation is required to prove medical necessity for CPT 19318?

Required documentation includes: minimum 6 months of documented conservative treatment failures, photographs showing breast size and symptoms, objective symptom measurements (pain scores, grooving depth, rash severity), BMI/BSA calculations, Schnur scale assessment, operative report with tissue weights in grams, and pathology confirmation. Missing any element significantly increases denial risk.

Does CPT 19318 have a global period, and what does it include?

Yes, CPT 19318 has a 90-day global surgical period. This includes all preoperative visits (typically 1 day before through day of surgery), the procedure itself, and routine postoperative care for 90 days including wound care, drain removal, and complication management. Separately billable services during this period require appropriate modifiers (24, 25, 57, or 79).

Can CPT 19318 be billed for gynecomastia treatment in male patients?

No, CPT 19318 specifically describes breast reduction in the context of reduction mammaplasty typically performed on female patients. For male gynecomastia treatment, the appropriate codes are 19300 (mastectomy for gynecomastia) or 15772-15774 (excision of excess skin and tissue). Using 19318 for male patients will result in claim denial for incorrect code selection.

What are the most common reasons for denial of CPT 19318 claims?

The top denial reasons are: (1) insufficient medical necessity documentation - missing conservative treatment records or symptom severity evidence; (2) cosmetic exclusion - payer determines aesthetic rather than functional purpose; (3) inadequate tissue removal - grams removed don't meet threshold requirements; and (4) billing errors - improper bilateral modifier usage. Pre-authorization and comprehensive documentation prevent 80% of these denials.