Correct inverted nipple(s)

CPT code 19355 covers a surgical procedure to correct nipples that turn inward instead of pointing outward, a condition that can interfere with breastfeeding or cause cosmetic concerns.

Showing rates for

National Average

Base Medicare rate

$740.09

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

8.52

PE RVU (NF)

12.8

MP RVU

1.56

Total RVU

22.88

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

NCCI bundling edits

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Billing tips

Document medical necessity thoroughly to avoid cosmetic procedure denials—include functional impairment (inability to breastfeed, recurrent infections, hygiene issues) and psychological impact with supporting mental health documentation
Impact: Proper documentation converts potential $0 cosmetic denial to full $740.09 reimbursement; 60-70% of initial denials stem from inadequate medical necessity documentation
For bilateral procedures, verify payer policy on modifier 50 versus two line items with RT/LT modifiers before claim submission
Impact: Incorrect bilateral billing format causes 30-40% of bilateral claims to process as unilateral, losing approximately $370 in underpayment
Bill facility versus non-facility based on actual place of service—ASC or hospital outpatient (POS 22/24) uses facility rate $607.47, while office-based surgical suite (POS 11) uses non-facility rate $740.09
Impact: Correct POS coding ensures proper payment; incorrect POS triggers $132.62 differential and potential recoupment audits
When performed with breast reconstruction (19340, 19342, 19364), sequence codes by RVU value and append modifier 51 to lower-valued codes to maximize reimbursement
Impact: Proper sequencing prevents unnecessary reduction to the higher-paying code; improper sequencing can reduce total payment by 10-15%
Link appropriate ICD-10 diagnosis codes (N64.52 for retracted nipple, Q83.8 for congenital inversion) and avoid cosmetic diagnosis codes like Z41.1
Impact: Cosmetic diagnosis codes trigger automatic denials; proper medical diagnosis coding is essential for any payment versus $0
For revision procedures within 90-day global period, determine if complication (modifier 78), staged procedure (modifier 58), or unrelated procedure (modifier 79) to ensure separate payment

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Frequently asked questions

What is the Medicare reimbursement for CPT code 19355 in 2025?

For 2025, Medicare reimburses CPT 19355 at $740.09 for non-facility settings and $607.47 for facility settings (national average). The code has 22.88 total RVUs (8.52 work RVU, 12.8 non-facility PE RVU, 8.7 facility PE RVU, and 1.56 MP RVU) multiplied by the 2025 conversion factor of 32.3465.

Does Medicare cover inverted nipple correction surgery?

Medicare covers CPT 19355 only when medically necessary—not for purely cosmetic reasons. Medical necessity requires documentation of functional impairment such as recurrent infections, inability to breastfeed with documented attempts, hygiene complications, or significant psychological distress. Cosmetic correction alone is excluded from Medicare coverage.

How do you bill CPT 19355 for bilateral nipple correction?

For bilateral nipple correction, append modifier 50 to CPT 19355 for most payers, which typically reimburses at 150% of the unilateral rate. However, some commercial payers require two separate line items with RT and LT modifiers instead. Always verify payer-specific bilateral surgery policies before submitting claims to ensure proper payment.

What diagnosis codes support medical necessity for CPT 19355?

ICD-10 codes supporting medical necessity include N64.52 (retracted nipple), N64.53 (unilateral retracted nipple), Q83.8 (congenital malformation of breast), N61.1 (abscess of breast and nipple), and potentially N62 (hypertrophy of breast) when concurrent. Avoid Z41.1 (cosmetic surgery) as this triggers automatic denials.

Can CPT 19355 be billed with breast augmentation or reduction?

CPT 19355 can be billed with breast procedures like reduction (19318) or reconstruction codes, but review NCCI edits carefully. Append modifier 59 or XU if the nipple correction is a distinct, separately identifiable service beyond the primary breast procedure. Documentation must clearly support that 19355 addressed a separate issue requiring additional work beyond the primary procedure.

What is the global period for CPT 19355?

CPT 19355 has a 90-day global surgical period. All routine post-operative care within 90 days is bundled into the surgical payment. To bill separately during the global period, use modifier 58 for staged/related procedures, modifier 78 for complications requiring return to OR, or modifier 79 for unrelated procedures.

What are common reasons for CPT 19355 claim denials?

The most common denial reasons include: (1) insufficient documentation of medical necessity versus cosmetic intent, (2) incorrect bilateral modifier usage causing payment as unilateral, (3) bundling with concurrent breast procedures without proper modifier 59/XU, and (4) use of cosmetic diagnosis codes. Approximately 60-70% of initial denials relate to inadequate medical necessity documentation.