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CPT code 19357 covers the surgical placement of a tissue expander as part of breast reconstruction, typically after mastectomy. The expander is a temporary device that gradually stretches the skin and chest muscle to create space for a permanent breast implant.

Showing rates for

National Average

Base Medicare rate

$1,140.54

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

14.84

PE RVU (NF)

17.67

MP RVU

2.75

Total RVU

35.26

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

NCCI bundling edits

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Billing tips

Bill with modifier 50 for bilateral procedures rather than two line items with RT/LT to maximize reimbursement at 150% rate
Impact: Ensures proper bilateral payment of $1710.81 vs potential underpayment if billed incorrectly
Document medical necessity clearly when performed at the time of mastectomy, linking to cancer diagnosis or prophylactic indication with genetic testing results
Impact: Reduces denial rate by 60-70% for immediate reconstruction cases
Verify prior authorization requirements for commercial payers before scheduling, as many require pre-certification for breast reconstruction despite federal mandate
Impact: Prevents payment delays of 30-90 days and reduces denial rate from 25% to under 5%
Bill on the same claim as mastectomy code (19303, 19304, 19305, 19306, 19307) when performed as immediate reconstruction to demonstrate continuity of care
Impact: Streamlines processing and reduces payer requests for additional documentation by approximately 40%
Document expander size, manufacturer, and lot number in operative report for device tracking and to support supply billing
Impact: Ensures separate reimbursement for the tissue expander device supply, typically $800-$2000 depending on payer
When using modifier 22, include a detailed addendum explaining the increased complexity with specific comparative time and difficulty metrics
Impact: Increases modifier 22 approval rate from 15-20% to 60-70%, potentially adding $228-$570 to reimbursement

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Frequently asked questions

What is the Medicare reimbursement rate for CPT code 19357 in 2025?

The 2025 Medicare national average reimbursement for CPT 19357 is $1140.54 for both facility and non-facility settings. This rate is based on 35.26 total RVUs multiplied by the 2025 conversion factor of 32.3465. Bilateral procedures using modifier 50 reimburse at $1710.81.

How do you bill CPT 19357 for bilateral tissue expander placement?

For bilateral tissue expander placement, append modifier 50 to CPT 19357 on a single line item. This results in 150% payment ($1710.81 for Medicare). Do not bill two separate line items with RT and LT modifiers, as this may result in incorrect payment or denial.

Can CPT 19357 be billed with a mastectomy code on the same day?

Yes, CPT 19357 can be billed with mastectomy codes (19301-19307) when immediate reconstruction is performed. These are separately reportable procedures with no NCCI edits bundling them. Document both procedures clearly in the operative report and ensure medical necessity for immediate reconstruction is established.

What is the difference between CPT 19357 and 19325?

CPT 19357 is for tissue expander placement during breast reconstruction (typically after mastectomy), while CPT 19325 is for breast augmentation mammaplasty with prosthetic implant in cosmetic or non-reconstructive cases. Code 19357 is covered by insurance for reconstruction; 19325 is typically not covered as it's considered cosmetic.

What documentation is required to bill CPT 19357 without denials?

Required documentation includes: clear medical necessity (linking to mastectomy/cancer diagnosis), laterality specification, detailed operative report with expander size and placement technique, device information for tracking, patient counseling notes, and appropriate ICD-10 codes (Z42.1, Z90.1-, or Z85.3). Missing any element increases denial risk significantly.

How many RVUs is CPT code 19357 worth in 2025?

CPT 19357 has 35.26 total RVUs in 2025, consisting of 14.84 work RVUs, 17.67 practice expense RVUs (both facility and non-facility), and 2.75 malpractice RVUs. This is considered a high-value surgical code reflecting the complexity of breast reconstruction.

Does CPT 19357 require prior authorization from insurance?

Prior authorization requirements vary by payer. While the Women's Health and Cancer Rights Act (WHCRA) mandates coverage for breast reconstruction, many commercial insurers still require pre-certification for tissue expander placement. Medicare typically does not require prior authorization, but verify with specific Medicare Advantage plans. Always check payer-specific policies before scheduling.