Revj reconstructed breast

CPT code 19380 covers revision surgery on a previously reconstructed breast, typically performed to correct complications, improve cosmetic results, or address issues like capsular contracture or implant malposition after initial breast reconstruction.

Showing rates for

National Average

Base Medicare rate

$794.11

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

11.17

PE RVU (NF)

11.31

MP RVU

2.07

Total RVU

24.55

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

NCCI bundling edits

Loading bundling edits…

Billing tips

Document specific medical indications (pain, infection, implant malposition, capsular contracture grade) rather than cosmetic dissatisfaction to establish medical necessity
Impact: Reduces denial rate by 60-75%; cosmetic denials are difficult to overturn and result in complete loss of $794.11 reimbursement
When performing bilateral revisions, bill 19380-50 rather than two line items with RT/LT modifiers to ensure proper 150% payment
Impact: Ensures correct payment of $1,191.17 versus risk of only receiving payment for one side
If revision includes significant capsulectomy work, consider whether separate capsulectomy coding is appropriate based on payer bundling edits
Impact: May capture additional $200-400 in reimbursement when supported by documentation and not bundled
Verify whether the revision falls within the global period of the original reconstruction (typically 90 days); if so, modifier 78 or 58 is mandatory
Impact: Prevents automatic denial; incorrect modifier use results in 100% claim rejection
For complex revisions involving multiple components (implant exchange, fat grafting, flap revision), document each component's time and complexity to support modifier 22
Impact: Can increase reimbursement by $150-400 when additional payment is approved
Obtain prior authorization for revisions even when not explicitly required; many payers audit reconstruction revisions and retroactively deny without prior review
Impact: Reduces retroactive denials by 40-50%, protecting the full $794.11 payment

Live Field Datano reports yet

Real billers contribute denial patterns and appeal strategies for this code. Once 5+ reports come in, you’ll see live aggregated data here — the only place this exists, free.

Working with CPT 19380?

Get the free Revenue Protection Toolkit — the denial triggers, modifier pitfalls, and bundling conflicts that quietly cost you reimbursement. Instant download.

Help build the field knowledge

MedPayIQ gets smarter as billers contribute. If you've had this code denied, share what happened so others learn from it. Anonymous, no patient info.

Related actions

Frequently asked questions

What is the Medicare reimbursement rate for CPT 19380 in 2025?

The 2025 Medicare national average reimbursement for CPT 19380 is $794.11 for both facility and non-facility settings, based on 24.55 total RVUs and the 2025 conversion factor of 32.3465.

Does CPT 19380 cover cosmetic revision of breast reconstruction?

No, CPT 19380 requires medical necessity documentation. Purely cosmetic revisions for aesthetic preference without functional impairment, pain, or documented complication are typically not covered by insurance and would be patient responsibility.

Can I bill 19380 bilaterally with modifier 50?

Yes, when revising both reconstructed breasts during the same operative session, append modifier 50 for bilateral procedure billing, which typically reimburses at 150% of the unilateral rate ($1,191.17 under Medicare).

What modifier should I use for revision during the global period?

Use modifier 78 if the revision addresses a complication from the original reconstruction, or modifier 58 if the revision was a planned staged procedure. Modifier 78 typically results in reduced payment while modifier 58 allows full reimbursement.

How many RVUs is CPT code 19380 worth?

CPT 19380 has 24.55 total RVUs for 2025, consisting of 11.17 work RVUs, 11.31 practice expense RVUs, and 2.07 malpractice RVUs based on the CMS Medicare Physician Fee Schedule.

What documentation is required to prove medical necessity for 19380?

Required documentation includes specific clinical indications (capsular contracture grade, implant malposition, infection, pain scores), pre-operative photographs, details of the original reconstruction, failed conservative treatments when applicable, and a detailed operative report describing the revision work performed.

Can CPT 19380 be billed with breast implant removal codes?

This depends on payer-specific bundling edits (NCCI). When implant removal/exchange is the primary component of the revision, it is typically included in 19380. However, for extensive capsulectomy or removal for separate indication, additional coding may be appropriate with modifier 59 if supported by documentation and not bundled per NCCI.