Breast augmentation w/implt

CPT code 19325 covers breast augmentation surgery using an implant to increase breast size or restore volume. This is an elective cosmetic procedure in most cases, though it may be reconstructive after mastectomy or trauma.

Showing rates for

National Average

Base Medicare rate

$606.50

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

8.12

PE RVU (NF)

9.13

MP RVU

1.5

Total RVU

18.75

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

NCCI bundling edits

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Billing tips

Verify medical necessity documentation before billing Medicare or commercial payers; most breast augmentation is cosmetic and non-covered
Impact: Prevents claim denials and potential fraud allegations; cosmetic procedures should be patient-pay with advance written notice
For reconstructive cases, ensure documentation clearly establishes medical necessity (post-mastectomy, congenital deformity, trauma) and consider alternative codes like 19357 for post-mastectomy reconstruction
Impact: Proper code selection increases approval rate from near 0% to 85%+ for reconstructive cases; 19357 may reimburse higher than 19325
Use modifier 50 correctly for bilateral procedures and verify payer-specific bilateral surgery policies before submission
Impact: Proper modifier use can mean difference between 150% vs 200% reimbursement; incorrect use triggers automatic denials
Separately bill for implants using HCPCS codes (L8600 for silicone, L8601 for saline) when payer allows pass-through billing
Impact: Implant costs range $1,000-$3,000 per device; separate billing recovers costs beyond the $606.50 professional fee
Document implant specifications (manufacturer, model, size, serial number, silicone vs saline) in operative report for tracking and potential future recalls
Impact: Prevents denial on appeal and ensures compliance with FDA tracking requirements; essential for revision cases
For facility billing, verify whether case qualifies for non-facility vs facility rate; the $606.50 rate applies to both settings for 19325
Unusual that facility and non-facility rates match; confirms no additional payment differential for setting of service

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Frequently asked questions

Does Medicare cover CPT code 19325 for breast augmentation?

Medicare does not cover CPT 19325 when performed for purely cosmetic reasons. Coverage may apply only when medically necessary for reconstruction after mastectomy, trauma, or correction of congenital deformity. Even then, code 19357 may be more appropriate for post-mastectomy reconstruction. Patients should receive an Advance Beneficiary Notice (ABN) if non-coverage is expected.

What is the 2025 Medicare reimbursement rate for CPT 19325?

The 2025 Medicare national average reimbursement for CPT 19325 is $606.50 for both facility and non-facility settings, based on 18.75 total RVUs and a conversion factor of 32.3465. This represents only the professional fee and does not include the implant device cost, which is billed separately.

How do I bill CPT 19325 for bilateral breast augmentation?

For bilateral breast augmentation, append modifier 50 to CPT 19325, or alternatively bill the code twice with modifiers RT (right) and LT (left). Verify your payer's specific bilateral surgery policy, as reimbursement methodology varies. Most payers reimburse bilateral procedures at 150% of the unilateral rate when modifier 50 is used.

What is the difference between CPT 19325 and 19357?

CPT 19325 is for breast augmentation with implant (typically cosmetic or simple reconstruction), while 19357 describes tissue expander placement or permanent implant insertion as part of immediate or delayed breast reconstruction following mastectomy. Code 19357 is more appropriate for post-mastectomy reconstruction and typically has better insurance coverage and higher reimbursement.

Can I bill separately for breast implants with CPT 19325?

Yes, breast implants should be billed separately using HCPCS codes L8600 (silicone gel-filled breast implant) or L8601 (saline-filled breast implant). However, verify payer policy as Medicare typically does not cover implants for cosmetic procedures. The $606.50 reimbursement for 19325 covers only the surgical service, not the device.

What documentation is required to justify medical necessity for CPT 19325?

Medical necessity documentation must include diagnosis codes supporting reconstruction (not cosmetic enhancement), clinical notes explaining the medical indication (post-mastectomy, congenital deformity, trauma), pre-operative photographs, psychological evaluation if applicable, and a detailed operative report. For post-mastectomy cases, include mastectomy records and pathology reports.

What are the most common denial reasons for CPT 19325?

The most common denials include: cosmetic/not medically necessary determination, incorrect code selection (should be 19357 for reconstruction), missing bilateral modifiers, inadequate documentation of medical necessity, and billing to Medicare for non-covered cosmetic procedures. Proper code selection and comprehensive documentation are essential to prevent denials.