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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.

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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.

Service type: Surgical explantation of a tissue expander
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.

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CPT 11971: Removal of Tissue Expander Without Implant

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Billing Code Overview

Service type: Surgical explantation of a tissue expander
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

CPT 11900: Intralesional Corticosteroid Injection for Large Nodules and Keloids

CPT-11901-INTRALESIONAL-CORTICOSTEROID-INJECTION-LESION-TREATMENT

CPT 11901: Intralesional Corticosteroid Injection for Lesion Treatment

CPT-11920-MEDICAL-TATTOOING-PERMANENT-CAMOUFLAGE-SKIN-DEFECT

CPT 11920: Medical Tattooing for Skin Color Defects

CPT-11921-MEDICAL-TATTOOING-PERMANENT-CAMOUFLAGE-6-1-TO-20-CM2

CPT 11921: Medical Tattooing for Permanent Camouflage of Skin Defects

CPT-11922-PERMANENT-CAMOUFLAGE-MEDICAL-TATTOOING-ADDITIONAL-20CM2

CPT 11922: Medical Tattooing for Permanent Camouflage of Skin Defects

CPT-11950-SUBCUTANEOUS-COLLAGEN-INJECTION-1CC-OR-LESS

CPT 11950: Subcutaneous Collagen Injection, 1 cc or Less

CPT-11951-COLLAGEN-INJECTION-SUBCUTANEOUS-1-1-TO-5-0-CC

CPT 11951: Collagen Injection, 1.1 cc to 5.0 cc Subcutaneous

CPT-11952-COLLAGEN-SUBCUTANEOUS-INJECTION-5-1-TO-10-0-CC

CPT 11952: Collagen Injection, Subcutaneous 5.1–10.0 cc

CPT-11954-COLLAGEN-INJECTION-SUBCUTANEOUS-MORE-THAN-10CC

CPT 11954: Injection of >10.0 cc Collagen into Subcutaneous Tissue

CPT-11960-TISSUE-EXPANDER-PLACEMENT-NON-BREAST-RECONSTRUCTION

CPT 11960: Tissue Expander Placement for Non‑Breast Reconstruction

Showing 1–10 of 16

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

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Clinical & Coding Specifications

Clinical Context

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

CPT 11900: Intralesional Corticosteroid Injection for Large Nodules and Keloids

CPT-11901-INTRALESIONAL-CORTICOSTEROID-INJECTION-LESION-TREATMENT

CPT 11901: Intralesional Corticosteroid Injection for Lesion Treatment

CPT-11920-MEDICAL-TATTOOING-PERMANENT-CAMOUFLAGE-SKIN-DEFECT

CPT 11920: Medical Tattooing for Skin Color Defects

CPT-11921-MEDICAL-TATTOOING-PERMANENT-CAMOUFLAGE-6-1-TO-20-CM2

CPT 11921: Medical Tattooing for Permanent Camouflage of Skin Defects

CPT-11922-PERMANENT-CAMOUFLAGE-MEDICAL-TATTOOING-ADDITIONAL-20CM2

CPT 11922: Medical Tattooing for Permanent Camouflage of Skin Defects

CPT-11950-SUBCUTANEOUS-COLLAGEN-INJECTION-1CC-OR-LESS

CPT 11950: Subcutaneous Collagen Injection, 1 cc or Less

CPT-11951-COLLAGEN-INJECTION-SUBCUTANEOUS-1-1-TO-5-0-CC

CPT 11951: Collagen Injection, 1.1 cc to 5.0 cc Subcutaneous

CPT-11952-COLLAGEN-SUBCUTANEOUS-INJECTION-5-1-TO-10-0-CC

CPT 11952: Collagen Injection, Subcutaneous 5.1–10.0 cc

CPT-11954-COLLAGEN-INJECTION-SUBCUTANEOUS-MORE-THAN-10CC

CPT 11954: Injection of >10.0 cc Collagen into Subcutaneous Tissue

CPT-11960-TISSUE-EXPANDER-PLACEMENT-NON-BREAST-RECONSTRUCTION

CPT 11960: Tissue Expander Placement for Non‑Breast Reconstruction

Showing 1–10 of 16

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

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CPT 11971: Removal of Tissue Expander Without Implant

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Billing Code Overview

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CPT 11971: Removal of Tissue Expander Without Implant

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Billing Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References