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The procedure described by CPT® Code 19371 refers to a complete peri-implant capsulectomy of the breast, which involves the surgical removal of the fibrous capsule that forms around a breast implant. This capsule, often a result of the body’s natural healing response, can lead to complications such as capsular contraction, where the scar tissue becomes thickened and may cause the breast to appear distorted, feel hard, and potentially be painful. In some cases, this condition can also lead to the formation of calcifications or adhesions to the surrounding tissue, further complicating the situation. The complete capsulectomy procedure entails not only the excision of the capsule itself but also the removal of all intracapsular contents, which may include the breast implant and any associated materials. This procedure is typically indicated for patients experiencing significant issues with thickened or calcified scar tissue capsules or those with ruptured implants. The surgical approach generally involves making an incision along the breast crease to access the capsule, allowing the surgeon to carefully dissect surrounding tissue and assess the condition of the capsule. Depending on the findings, the surgeon may employ an enbloc technique to remove the entire capsule and implant in one piece, minimizing the risk of leakage from ruptured implants. Alternatively, if the capsule is thin or adherent to other structures, the surgeon will proceed with the necessary steps to ensure complete removal of the capsule and its contents while preserving surrounding tissue as much as possible.
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The peri-implant capsulectomy procedure described by CPT® Code 19371 is indicated for several specific conditions related to breast implants. These include:
The procedure for a complete peri-implant capsulectomy involves several critical steps to ensure thorough removal of the capsule and its contents. The process begins with the surgeon making an incision along the breast crease, which is strategically placed to minimize visible scarring. Once the incision is made, the surgeon carefully separates the tissue to expose the fibrous capsule surrounding the implant. This dissection is performed with precision to avoid damaging surrounding structures. After exposing the capsule, the surgeon assesses its consistency; if the capsule appears normal or only slightly thickened without significant adhesions, an enbloc technique is employed. This technique allows for the removal of the entire capsule along with the implant in one cohesive piece, which is particularly beneficial in preventing leaks from ruptured implants. In cases where the capsule is found to be thin or adherent to the ribs or other tissues, the surgeon will proceed with careful excision of the capsule and all intracapsular contents, ensuring that all materials are removed while preserving as much surrounding tissue as possible. This meticulous approach is essential for alleviating symptoms and restoring the natural appearance of the breast.
After the completion of the peri-implant capsulectomy, patients can expect a recovery period that may involve monitoring for any complications such as infection or excessive bleeding. Post-operative care typically includes pain management, wound care instructions, and follow-up appointments to assess healing. Patients may experience swelling and discomfort in the initial days following the procedure, which is a normal part of the healing process. It is important for patients to adhere to their surgeon's guidelines regarding activity restrictions and care of the surgical site to promote optimal recovery. The expected outcome of the procedure is a reduction in symptoms associated with capsular contraction and an improved aesthetic appearance of the breast.
| Short Descr | PERI-IMPLT CAPSLC BRST COMPL | Medium Descr | PERI-IMPLANT CAPSULECTOMY BREAST COMPLETE | Long Descr | Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1A - Major procedure - breast | MUE | 1 | CCS Clinical Classification | 175 - Other OR therapeutic procedures on skin and breast |
| 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | LT | Left side (used to identify procedures performed on the left side of the body) | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | RT | Right side (used to identify procedures performed on the right side of the body) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | SG | Ambulatory surgical center (asc) facility service | GC | This service has been performed in part by a resident under the direction of a teaching physician | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 77 | Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AG | Primary physician | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | GA | Waiver of liability statement issued as required by payer policy, individual case | GJ | "opt out" physician or practitioner emergency or urgent service | GX | Notice of liability issued, voluntary under payer policy | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | GZ | Item or service expected to be denied as not reasonable and necessary | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2021-01-01 | Changed | Code changed. |
| Pre-1990 | Added | Code added. |
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