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CPT 19318: Breast Reduction Surgery
CPT code 19318 represents breast reduction surgery to remove excess breast tissue associated with scarring, calcification, or architectural distortion. This procedure is clinically important for addressing functional impairment, symptomatic tissue changes, and reconstructive needs, and it has implications for coverage, prior authorization, and provider reimbursement nationally. Payers commonly involved in coverage decisions for this code include Aetna, Blue Cross Blue Shield, Cigna Health, United Healthcare, and Medicare. Readers will find a concise overview of the clinical context for 19318, how it relates to adjacent breast surgery codes, and the payer landscape relevant to authorization and coverage policies. The publication summarizes typical sites of service, common clinical indications, and coding relationships to related procedures such as mastopexy and breast augmentation or reconstruction. It also provides benchmarks and policy summaries where available and highlights payer-specific policy features that influence claims processing and medical necessity determinations. The content is aimed at clinicians, billing professionals, and policy analysts seeking a national-level reference for coding, clinical context, and payer considerations for CPT code 19318.
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Billing Code Overview
CPT code 19318 describes breast reduction performed to remove excess breast tissue resulting from top scarring, calcification, or architectural distortion. The procedure is a reconstructive and/or reductive breast surgery intended to address symptomatic or structural changes in breast tissue.
Service Type: Breast reduction surgery
Typical Site of Service: Hospital operating room or ambulatory surgical center
National Reimbursement Benchmarks
Nationwide averages place Medicare substantially lower than BUCA’s commercial average: Medicare’s mean is $997.40 versus BUCA’s mean of $3,239.60, a gap of $2,242.20 that highlights a sizeable differential between government and commercial payment levels for CPT 19318. Other major commercial payers fall between these points, with Aetna, Cigna, Blue Cross Blue Shield, and UnitedHealth Group showing higher means than Medicare but varying widely among themselves.
Looking at dispersion using the interquartile range (P75–P25), Blue Cross Blue Shield exhibits the widest spread at $5,932.60, indicating the greatest variability in market rates. Aetna’s IQR is $1,215.00 and BUCA’s IQR is $3,342.10; UnitedHealth Group and Cigna have moderate spreads of $1,196.10 and $1,255.20 respectively, making UnitedHealth Group the tightest among the listed commercial payers by this measure.