Insj/rplcmt brst implt sep d

CPT code 19342 covers the surgical insertion or replacement of a breast implant performed on a separate day from the initial mastectomy or breast surgery. This includes reconstructive procedures where the implant is placed in a previously created pocket.

Showing rates for

National Average

Base Medicare rate

$748.82

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

10.48

PE RVU (NF)

10.75

MP RVU

1.92

Total RVU

23.15

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

NCCI bundling edits

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Billing tips

Always append RT or LT modifier to indicate laterality; use modifier 50 for bilateral procedures rather than billing two line items
Impact: Prevents automatic denial for missing laterality; proper bilateral coding ensures correct $1,123.23 payment vs. risk of single-side payment only
Document the separate date of service from mastectomy or tissue expander placement to support the 'separate day' component of the descriptor
Impact: Critical for distinguishing from immediate reconstruction codes (19340, 19361) which have different reimbursement rates and avoid bundling denials
Use modifier 58 when implant insertion follows tissue expander placement during the global period, with documentation showing staged/planned approach
Impact: Preserves full $748.82 reimbursement that would otherwise be denied as included in global surgical package
For revision cases, clearly document medical necessity (capsular contracture, implant rupture, malposition) to distinguish from cosmetic adjustments
Impact: Difference between full reimbursement and complete denial; Medicare does not cover cosmetic procedures
Bill with appropriate diagnosis codes linking to breast cancer history (Z85.3), post-mastectomy status (Z90.1-), or complications (T85.42XA for capsular contracture)
Impact: Establishes medical necessity for reconstruction; incorrect diagnosis coding is the #1 cause of denials for this procedure
When billing with modifier 22, include detailed operative note highlighting specific increased complexity factors and extra time (typically 25%+ beyond usual)
Potential additional reimbursement of $150-$375 when properly documented, but <30% approval rate without compelling documentation

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 19342 in 2025?

The 2025 Medicare national average reimbursement for CPT 19342 is $748.82 for both facility and non-facility settings, based on 23.15 total RVUs and the conversion factor of 32.3465.

Does CPT 19342 cover bilateral breast implant insertion?

CPT 19342 describes a unilateral procedure. For bilateral implant insertion, append modifier 50 to indicate bilateral procedure, which typically reimburses at 150% of the unilateral rate ($1,123.23). Alternatively, some payers prefer two line items with RT and LT modifiers.

What is the difference between CPT 19340 and 19342?

CPT 19340 is for immediate breast implant insertion at the time of mastectomy, while 19342 is for insertion or replacement of an implant on a separate day from the mastectomy. Code 19342 is typically used for delayed reconstruction after tissue expansion or for implant replacement procedures.

How do I bill for breast implant replacement after complications?

Use CPT 19342 with appropriate diagnosis codes indicating the complication (such as T85.42XA for capsular contracture or T85.43XA for implant rupture). Documentation must clearly establish medical necessity and link the replacement to a complication rather than cosmetic preference.

Can CPT 19342 be billed with tissue expander removal code 11971?

Yes, but these codes may bundle depending on the payer. When performed together (exchange of expander for implant), append modifier 59 or XU to code 11971 to indicate a distinct procedural service. Documentation should clearly show both removal and insertion as separate, medically necessary components.

What diagnosis codes support medical necessity for CPT 19342?

Primary diagnosis codes include Z90.1- (acquired absence of breast), Z85.3 (personal history of breast malignancy), T85.42XA (capsular contracture), T85.43XA (implant rupture), or N64.82 (hypoplasia of breast). Link to the specific medical indication for reconstruction or replacement.

How many RVUs is CPT code 19342 worth in 2025?

CPT 19342 has 23.15 total RVUs in 2025, consisting of 10.48 work RVUs, 10.75 practice expense RVUs (both facility and non-facility), and 1.92 malpractice RVUs, making it a moderately high-value surgical procedure.