Summary & Overview
CPT 11971: Removal of Tissue Expander Without Implant
CPT code 11971 reports the surgical removal of a tissue expander without placement of a permanent implant. This code is relevant nationally for reconstructive and cosmetic breast procedures and other soft-tissue reconstruction pathways that use expanders as a staged approach. Accurate use of 11971 affects claims processing, payment determinations, and clinical documentation for explantation-only procedures.
Key payers commonly involved in coverage decisions include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find national-oriented context on clinical indications for explantation-only procedures, the typical sites of service (ambulatory surgery centers and hospital operating rooms), and the coding circumstances that distinguish removal without implant from combined-exchange procedures.
This publication provides benchmarks and policy context for payers listed above, outlines common billing scenarios where 11971 applies, and summarizes documentation elements and coding distinctions relevant to claims. Data not available in the input for payer-specific rates and utilization metrics.
Billing Code Overview
CPT code 11971 describes the surgical removal of a tissue expander without insertion of an implant. This procedure typically involves explantation of a temporary, often saline or silicone-based, device that was placed to stretch soft tissue and create a pocket for a future permanent implant.
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Service type: Surgical explantation of a tissue expander
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Typical site of service: Ambulatory surgery center or hospital operating room
This code is used when the tissue expander is removed and no implant is placed during the same operative session. Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A typical patient is a woman who previously underwent mastectomy with placement of a temporary tissue expander as part of a staged breast reconstruction. After completion of adjuvant therapy or adequate expansion and soft-tissue conditioning, the plastic surgeon schedules removal of the tissue expander without immediate insertion of a permanent implant due to planned delayed reconstruction, patient preference, or intraoperative findings (e.g., infection, thin soft-tissue envelope). The procedure is performed in an ambulatory surgery center or hospital operating room under general anesthesia or monitored anesthesia care.
Preoperative workflow includes surgical planning, review of prior operative notes and imaging, verification of the expander type and port location, and counseling on risks such as hematoma, seroma, infection, and need for drain placement. Intraoperative steps include incision through prior scar, careful dissection to the expander capsule, control of the port and tubing if present, removal of the expander, assessment of the capsule and surrounding tissues, irrigation, possible capsulectomy or drain placement, and layered wound closure. Postoperative workflow includes recovery monitoring, wound care instructions, pain control, and scheduling of future reconstructive steps if applicable.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
52 | Reduced services | When the removal is abbreviated or fewer services than described by protocol are performed |
53 | Discontinued procedure | When procedure is started but terminated due to intraoperative complication or patient condition |
59 | Distinct procedural service | When reporting a separate, distinct procedure on the same day unrelated to the expander removal |
62 | Two surgeons | When two surgeons work together as primary surgeons on the same procedure |
76 | Repeat procedure by same physician | Data not available in the input. |
78 | Return to OR for related procedure during postoperative period | When patient returns to the operating room for a complication related to the removal |
79 | Unrelated procedure or service by same physician during postoperative period | When an unrelated procedure is performed during the global period |
LT | Left side | When procedure is performed on the left breast |
RT | Right side | When procedure is performed on the right breast |
51 | Multiple procedures | When multiple procedures are performed at the same operative session and bundling rules apply |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
| Data not available in the input. | Plastic Surgery | Most commonly performed by board-certified plastic surgeons specializing in reconstructive breast surgery |
| Data not available in the input. | General Surgery | Sometimes performed by general surgeons with breast surgery expertise, especially in oncologic practices |
| Data not available in the input. | Surgical Oncology | Performed when coordinated with oncologic care for mastectomy and reconstruction planning |
| Data not available in the input. | Otolaryngology—Head & Neck Surgery | Rarely involved when complex chest wall or soft-tissue issues overlap |
| Data not available in the input. | Anesthesiology | Provides anesthesia services for the procedure |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
T85.21XA | Breakdown (mechanical) of breast prosthesis, initial encounter | Relevant when an expander malfunction or mechanical failure necessitates removal |
T85.29XA | Other mechanical complication of other internal prosthetic device, initial encounter | Used when a non-specific mechanical issue with the expander is present |
T81.4XXA | Infection following a procedure, initial encounter | Applied when postoperative or device-related infection drives expander removal |
N64.89 | Other specified disorders of breast | Used for non-specific breast soft-tissue complications associated with expanders |
Z42.1 | Encounter for breast reconstruction following mastectomy | Used to indicate staged reconstructive care including expander removal as part of reconstruction planning |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
19380 | Revision of reconstructed breast | Performed when revision or capsulectomy is required after expander removal and before or instead of implant placement |
19357 | Tissue expander placement in breast reconstruction | Represents the initial placement of the tissue expander earlier in the staged reconstruction sequence |
11970 | Replacement of tissue expander with prosthesis | Performed when the expander is removed and immediately replaced with a permanent implant during the same operative session |
36415 | Collection of venous blood by venipuncture | Commonly performed perioperatively for labs such as CBC or type and screen prior to surgery |
99024 | Postoperative follow-up visit (global period) | Used for routine postoperative visits during the global surgical period |