Peri-implt capslc brst compl

CPT 19371 covers the complete surgical removal of scar tissue (capsule) that forms around a breast implant. This procedure is performed when the capsule causes complications like hardening, pain, or implant malposition.

Showing rates for

National Average

Base Medicare rate

$701.60

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

9.98

PE RVU (NF)

9.83

MP RVU

1.88

Total RVU

21.69

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

NCCI bundling edits

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Billing tips

Document Baker Grade classification and specific symptoms (pain scale, contracture severity, functional limitation) to establish medical necessity
Impact: Prevents up to 30% denial rate for cosmetic designation; ensures full $701.60 reimbursement
When billing bilateral procedures (modifier 50), verify payer-specific bilateral rules as some require separate line items with RT/LT instead
Impact: Incorrect bilateral billing can reduce payment from expected $1,052.40 to only $701.60
Separately bill implant removal (19328) when performed with capsulectomy, as these are distinct procedures not bundled by NCCI
Impact: Captures additional $384-$447 in reimbursement when both procedures are medically necessary and documented
Use modifier 22 with comprehensive documentation when capsulectomy requires extensive dissection due to radiation history, multiple prior surgeries, or infection
Impact: Can increase reimbursement by $140-$350 (20-50% increase) with proper comparative documentation
Submit pathology report showing complete capsule specimen to confirm 'complete' capsulectomy rather than partial removal
Impact: Prevents downcoding to unlisted procedure or partial capsulectomy; protects full 21.69 RVU payment
For reconstruction cases, verify if 19371 or reconstruction codes (19357-19369) better represent the total work performed
Impact: Reconstruction codes may reimburse $1,200-$2,800 vs. $701.60 for capsulectomy alone when tissue expander/implant exchange is primary procedure

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 19371 in 2025?

The 2025 Medicare national average reimbursement for CPT 19371 is $701.60 for both facility and non-facility settings, based on 21.69 total RVUs and a conversion factor of $32.3465.

Can CPT 19371 be billed with implant removal code 19328?

Yes, CPT 19371 (complete capsulectomy) can be billed separately with 19328 (breast implant removal) as they are not bundled by NCCI edits. Both procedures represent distinct work when the capsule is completely removed beyond simple implant extraction.

What modifier should I use for bilateral breast capsulectomy?

Use modifier 50 for bilateral complete capsulectomy, which typically reimburses at 150% of the unilateral rate ($1,052.40). Some payers require two separate line items with RT/LT modifiers instead, so verify payer-specific bilateral policies.

Is CPT 19371 covered by Medicare for cosmetic breast augmentation complications?

Medicare covers 19371 only when medically necessary for complications like symptomatic capsular contracture (Baker Grade III/IV), infection, or pain causing functional impairment. Purely cosmetic concerns related to elective augmentation are not covered.

What documentation is required to prove medical necessity for CPT 19371?

Required documentation includes Baker Grade classification (III or IV preferred), physical exam findings showing firmness/distortion, pain assessment, failed conservative treatment, imaging if performed, and operative report explicitly describing complete capsule removal with pathology submission.

How many RVUs is CPT 19371 worth in 2025?

CPT 19371 has 21.69 total RVUs in 2025, consisting of 9.98 work RVUs, 9.83 practice expense RVUs (both facility and non-facility), and 1.88 malpractice RVUs.

What is the difference between complete capsulectomy (19371) and partial capsulectomy?

CPT 19371 specifically describes complete removal of the entire fibrous capsule surrounding the implant, requiring circumferential dissection and excision. Partial capsulectomy or capsulotomy (cutting/releasing the capsule) would require an unlisted code and typically reimburses at lower rates.