Summary & Overview
CPT 19396: Custom Breast Mold for Mastectomy Reconstruction
CPT code 19396 represents the fabrication of a custom breast mold or model used to plan and create a personalized implant for patients undergoing mastectomy reconstruction. This planning procedure identifies chest wall or other deformities to ensure a better reconstructive fit and is a critical step in achieving optimal cosmetic and functional outcomes after mastectomy. Nationally, accurate reporting of this code supports appropriate care coordination between surgical teams and prosthetic services and informs utilization patterns in reconstructive breast surgery.
Key payers considered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of how 19396 is defined and used clinically, typical sites of service, and the service type. The publication summarizes common payer coverage considerations and benchmarking context where available. It also outlines policy-relevant details and clinical context that affect billing and documentation for custom breast mold services.
Expected takeaways include clear definitions of the procedure and its role in reconstruction, payer coverage scope at a national level, and where to look for coding and documentation requirements. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 19396 describes the creation of a customized breast mold or model that closely matches a mastectomy patient's remaining breast. The provider uses this mold to design a personalized breast implant, documenting any chest wall or other deformity to optimize reconstruction outcomes.
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Service type: Surgical/constructive planning for breast reconstruction
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Typical site of service: Outpatient surgical or procedure setting, frequently performed in a surgical clinic or ambulatory surgery center where preoperative prosthetic modeling and reconstruction planning occur
Clinical & Coding Specifications
Clinical Context
A 54-year-old woman with a history of left-sided mastectomy for invasive ductal carcinoma presents for preoperative planning for two-stage implant-based reconstruction. The plastic surgeon evaluates the mastectomy defect, chest wall contour, and the contralateral breast to plan a custom implant. In the clinic, the provider creates a three-dimensional mold/model that closely reproduces the patient’s remaining breast and identifies chest wall deformities, scar contractures, or asymmetries. Measurements and a customized model are used to fabricate a patient-specific implant or implant cover to optimize symmetry at the time of reconstructive surgery. Typical workflow includes preoperative consultation, physical exam and anthropometric measurements, molding/sculpting session in clinic or prosthetics lab, documentation of laterality and any complicating anatomy, and coordination with the operating surgeon and prosthetics vendor for production of the customized implant. Typical site of service is an outpatient surgical clinic or ambulatory surgical center with prosthetics/implant fabrication coordinated through a surgical supply vendor.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
11 | Normal value, professional service | Use when billed by the primary surgeon performing the molding as the usual service. |
22 | Increased procedural services | Use when the molding requires substantially greater work due to complex chest wall deformity or extensive corrective modeling. |
52 | Reduced services | Use when the molding procedure is partially reduced or not completed. |
53 | Discontinued procedure | Use when the molding is started but terminated due to patient intolerance or unexpected findings. |
59 | Data not available in the input. | Data not available in the input. |
62 | Two surgeons | Use when two surgeons of different specialities collaborate on the molding/implant planning. |
63 | Procedure performed on infants/children | Rarely applicable; use if patient is pediatric. |
76 | Data not available in the input. | Data not available in the input. |
78 | Unplanned return to the operating/procedural room | Use if molding is repeated intraoperatively due to unexpected needs. |
80 | Assistant surgeon | Use when an assistant surgeon provides significant technical services during the molding or intraoperative adjustment. |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
| 207S00000X | Plastic and Reconstructive Surgery | Primary specialty performing breast reconstruction and custom implant modeling. |
| 204L00000X | General Surgery | General surgeons who perform mastectomy and may participate in reconstruction planning. |
| 363L00000X | Prosthetics/Orthotics | Specialists or vendors who fabricate customized implants or external molds; clinical liaisons often coordinate with surgeons. |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
C50.912 | Malignant neoplasm of unspecified site of left female breast | Common indication for mastectomy leading to need for customized implant modeling. |
Z90.12 | Acquired absence of left breast and nipple | Post-mastectomy anatomic status requiring custom implant modeling for symmetry. |
N64.89 | Other specified disorders of breast | Breast deformities or scarring affecting mold design. |
T87.49 | Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, subsequent encounter | Relevant when prior implant complications necessitate custom implant planning. |
M21.71 | Other acquired deformity of chest wall, left side | Chest wall deformities that must be identified and accommodated in the custom mold. |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
19357 | Tissue expander placement in breast reconstruction | Often performed before definitive implant shaping; molds help plan final implant after expansion. |
19340 | Immediate insertion of breast implant following mastopexy, mastectomy or in reconstruction | Definitive implant insertion that may use custom implant molded with 19396. |
19342 | Delayed insertion of breast implant following mastectomy | Used when implantation occurs in a delayed reconstruction; molding guides implant selection. |
11970 | Local tissue rearrangement, breast | Adjunctive procedures for contouring that may be planned based on mold findings. |
19499 | Unlisted procedure, breast | Used for novel or custom implant fabrication steps not otherwise specified; related to custom modeling workflow. |