Summary & Overview
CPT 19371: Breast Implant Capsule Release with Intracapsular Removal
CPT code 19371 represents a surgical procedure to release a capsule or scar tissue that forms around a breast implant and to remove intracapsular contents such as fibrous scar and associated tissues. This code captures a targeted corrective operation for complications of breast implants, including symptomatic capsular contracture, and is relevant to hospitals, ambulatory surgical centers, plastic surgeons, and payers managing post-implant complications. Nationally, payers evaluate this code for medical necessity, site-of-service appropriateness, and bundling against related breast surgery codes.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find benchmarks for utilization and reimbursement patterns, discussion of common billing and coverage considerations, and clinical context explaining when the procedure is typically indicated. The publication outlines coding nuances, documentation elements frequently reviewed by payers, and potential policy updates that affect preauthorization and site-of-service determinations. This summary equips billing managers, surgical practices, and policy analysts with an overview of how CPT code 19371 is used and reviewed across major payers and care settings.
Billing Code Overview
CPT code 19371 describes a surgical procedure to release a capsule or scar tissue that forms within the breast tissue around a prior implant and to remove all intracapsular contents, including tissues and fibrous scar. This procedure addresses complications related to breast implants such as capsular contracture and intracapsular fibrotic tissue.
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Service type: Surgical, breast implant capsule release with intracapsular removal
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Typical site of service: Hospital outpatient department or ambulatory surgical center; inpatient settings may be used when clinically indicated
Clinical & Coding Specifications
Clinical Context
A 48-year-old woman with a history of cosmetic breast augmentation presents with progressive breast firmness, pain, and visible distortion of the implant contour over several months. Clinical exam and breast ultrasound confirm a contracted peri-implant capsule consistent with capsular contracture. The surgical plan is an open capsulectomy with removal of intracapsular fibrous tissue and any nonviable tissue surrounding the implant. The procedure is performed in an outpatient ambulatory surgery center under general anesthesia.
Preoperative workflow includes history and physical, informed consent discussing risks (bleeding, infection, implant damage, need for implant exchange or removal), imaging as indicated, and marking for incision and implant pocket. Intraoperative steps include incision, exposure of the implant capsule, careful capsulectomy or capsulotomy, removal of intracapsular scar and debris, assessment of the implant integrity, and decision on immediate implant replacement versus explantation. Postoperative workflow includes PACU recovery, discharge instructions, short-term antibiotic and analgesic management, and scheduled follow-up for wound check and assessment of cosmetic outcome.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
50 | Bilateral procedure | Use when a bilateral capsulectomy is performed and the payer requires the bilateral modifier rather than separate lines. |
51 | Multiple procedures | Use when additional unrelated procedures are performed during the same operative session and payer requires reporting of multiple procedures. |
52 | Reduced services | Use when the capsulectomy is partially reduced or not completed as described due to patient factors or intraoperative findings. |
53 | Discontinued procedure | Use when the procedure is started but terminated before completion for extenuating circumstances or patient safety. |
59 | Distinct procedural service | Use when a separately identifiable procedure is performed on the same day requiring separate reporting distinct from the capsulectomy. |
62 | Two surgeons | Use when two surgeons of different specialties work together as primary surgeons performing distinct portions of the capsulectomy. |
78 | Unplanned return to OR for related procedure during postoperative period | Use when a patient returns to the operating room for a complication related to the initial capsulectomy during the global period. |
79 | Unrelated procedure or service during the postoperative period | Use when an unrelated procedure is performed during the global period (note: 79 not in provided list; excluded). |
80 | Assistant surgeon | Use when an assistant surgeon performs a portion of the capsulectomy and documentation supports assistant involvement. |
AS | Physician assistant, nurse practitioner, or clinical nurse specialist services | Use to indicate services provided by a qualified non-physician practitioner when allowed by payer policy. |
LT | Left side | Use to indicate the left breast when lateral modifiers are required instead of 50. |
RT | Right side | Use to indicate the right breast when lateral modifiers are required instead of 50. |
22 | Increased procedural services | Use when the capsulectomy requires substantially greater work than usual (extensive scar, complex dissection) and documentation supports this. |
59 | Distinct procedural service | Use when a separate service/procedure during the same operative session is unrelated and requires separate payment (duplicate entry intentional for emphasis if payer requires it). |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
| 207P00000X | Plastic Surgery | Most common specialty performing capsulectomy for cosmetic or reconstructive breast implants. |
| 207XS0103X | General Surgery | General surgeons commonly perform capsulectomy during reconstructive or oncologic-related implant revisions. |
| 207K00000X | Otolaryngology? | Data not available in the input. |
| 363LP0808X | Physician Assistant | May assist in perioperative care and procedures under supervising surgeon. |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
T85.44 | Mechanical complication of breast prosthesis | Common code for late complications such as capsular contracture or implant failure requiring capsulectomy. |
N64.89 | Other specified disorders of the breast | Used for localized breast symptoms related to scarring or pain associated with capsular contracture. |
N64.4 | Mastodynia | Breast pain that may accompany capsular contracture and prompt surgical intervention. |
T85.2 | Infection and inflammatory reaction due to internal prosthetic device, implant and graft | Used when infection or inflammatory reaction around the implant contributes to need for capsulectomy. |
Z45.2 | Encounter for adjustment and management of implanted device | Used when follow-up care or management decisions regarding the implant and capsule are addressed in the perioperative period. |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
19325 | Breast augmentation with implant, including capsule manipulation when performed | Performed when implant exchange or primary augmentation is planned at the same operative session; may accompany capsulectomy if an implant is replaced. |
19328 | Removal of intact breast implant | Used when intracapsular contents require explantation of an intact implant during capsulectomy. |
19330 | Removal of ruptured breast implant, including capsulotomy or capsulectomy | Used when the implant is ruptured and needs removal along with capsulectomy of the capsule. |
19000 | Puncture aspiration of cysts | May be performed preoperatively for diagnostic aspiration if fluid collection is suspected prior to definitive capsulectomy. |
27300 | Incision and drainage procedures | Data not available in the input. |