Design custom breast implant

CPT code 19396 covers the design and creation of a custom breast implant specifically manufactured to match a patient's unique anatomical needs. This is not the surgical placement of the implant, but rather the planning, measurement, and design work required to create a personalized implant.

Showing rates for

National Average

Base Medicare rate

$261.04

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

2.17

PE RVU (NF)

5.51

MP RVU

0.39

Total RVU

8.07

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

NCCI bundling edits

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Billing tips

Bill 19396 separately from the implant placement procedure (CPT 19340, 19342, 19357, etc.) as this code represents the design work, not the surgery
Impact: Ensures capture of $261.04 non-facility payment that would otherwise be lost if only billing the placement code
Document the specific reasons standard implants are inadequate, including measurements, imaging findings, and anatomical limitations in the medical record
Impact: Reduces denial rate by approximately 60-70% compared to claims without detailed medical necessity documentation
Submit 19396 when the design work is completed, which may be weeks before the actual implant placement surgery
Impact: Accelerates cash flow and prevents bundling issues; allows for appropriate date-of-service billing separate from surgical date
Include manufacturer correspondence, custom design specifications, and 3D imaging or modeling documentation with initial claim submission
Impact: Decreases payer review time by 40-50% and significantly reduces supplemental documentation requests
Verify that the custom implant qualifies as FDA-approved patient-specific device rather than experimental device before billing
Impact: Prevents automatic denials for experimental procedures; FDA clearance documentation may increase approval rate to over 85%
Use modifier 50 for bilateral cases rather than billing two line items with RT/LT, as most payers prefer the modifier approach for this code
Impact: Reduces processing delays and improves clean claim rate by approximately 25% compared to line-item billing

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 19396 in 2025?

The 2025 Medicare national average reimbursement for CPT 19396 is $261.04 for non-facility settings and $139.41 for facility settings. The code has a total RVU value of 8.07 (Work RVU: 2.17, Non-facility PE RVU: 5.51, Facility PE RVU: 1.75, MP RVU: 0.39) using the 2025 conversion factor of 32.3465.

Can CPT 19396 be billed with breast implant placement codes?

Yes, CPT 19396 can be billed separately from breast implant placement codes (19340, 19342, 19357, etc.) because it represents distinct professional work—the design and specification of a custom implant—rather than the surgical placement procedure. The codes have different dates of service in many cases, as design work typically occurs weeks before surgery. Proper documentation of the separate design work is essential to support billing both codes.

What documentation is required to bill CPT 19396?

Required documentation includes: detailed clinical rationale for why standard implants are inadequate, specific anatomical measurements and dimensions, imaging studies used in the design process, evidence of manufacturer communication regarding custom specifications, patient-specific design parameters (volume, projection, contour), timeline of design work, comparison of standard implant options considered and rejected, and FDA clearance documentation for the custom device.

How often is CPT 19396 denied by insurance companies?

CPT 19396 experiences higher-than-average denial rates, typically 30-50% on initial submission, primarily due to medical necessity challenges and payer unfamiliarity with custom implant design as a separately billable service. Denials most commonly cite lack of medical necessity, bundling with surgical procedures, or experimental procedure designations. Strong upfront documentation can reduce denial rates to 15-20%.

What is the difference between CPT 19396 and standard breast implant codes?

CPT 19396 covers only the design and specification work for creating a custom breast implant tailored to a patient's unique anatomy—not the implant placement surgery itself. Standard breast implant codes (19340, 19342, etc.) cover the surgical procedure of placing pre-manufactured, off-the-shelf implants. Code 19396 is used when a patient's anatomy requires a uniquely manufactured implant that doesn't exist in standard sizing.

Who can bill CPT code 19396?

CPT 19396 is typically billed by board-certified plastic and reconstructive surgeons, breast surgical oncologists, or general surgeons with breast reconstruction privileges who have expertise in complex breast reconstruction. The physician must personally perform the design work, including measurements, imaging analysis, and specification development in collaboration with the implant manufacturer. This code requires substantial clinical expertise in breast anatomy and reconstruction techniques.

When should modifier 50 be used with CPT 19396?

Modifier 50 should be used with CPT 19396 when designing custom breast implants for both breasts during the same session. This is common in bilateral mastectomy reconstruction cases or severe bilateral asymmetry. Using modifier 50 typically results in 150% reimbursement of the unilateral rate (approximately $391.56 non-facility), which is the preferred billing method over submitting two separate line items with RT and LT modifiers.