2025 CPT code 19371
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Integumentary System Feed
Complete peri-implant capsulectomy of the breast, including removal of all intracapsular contents.
Modifiers may be applicable to 19371 in specific situations, such as for bilateral procedures (modifier 50), or to indicate specific circumstances of the service provided.
Medical necessity for 19371 must be established based on the patient's symptoms, such as pain, discomfort, or deformity related to capsular contracture, or the need for implant removal due to rupture or patient preference. Documentation should clearly support the medical rationale for the procedure.
The surgeon is responsible for performing the complete peri-implant capsulectomy. This includes preoperative planning, patient consent, surgical execution, and postoperative care.
In simple words: This procedure removes the scar tissue that can form around a breast implant. The surgeon makes an incision, removes the scar tissue capsule, and takes out any implant if one is present. The incision is then closed.
The physician performs a complete peri-implant capsulectomy of the breast, which involves surgically releasing the scar tissue capsule that forms around a breast implant. This procedure includes the removal of the entire capsule, along with any intracapsular contents like tissue and fibrous scar.The procedure typically begins with an incision along the existing mastectomy or implant scar. The surgeon then carefully dissects and removes the entire scar capsule surrounding the breast implant. Any implant present is also removed as part of this process. Finally, the incision is closed with sutures.
Example 1: A patient who underwent breast reconstruction with implants experiences capsular contracture and pain. A complete capsulectomy (19371) is performed to alleviate these symptoms and remove the contracted capsule., A patient with a history of ruptured silicone implants requires removal of the implant remnants and the surrounding capsule.The surgeon performs 19371 to remove the capsule and any remaining silicone material., A patient desires removal of their breast implants and no longer wants reconstruction.A complete capsulectomy (19371) is performed to remove both the implants and the surrounding capsules.
Documentation should include the presence and severity of capsular contracture, patient symptoms, operative details describing the extent of the capsulectomy, implant information (if applicable), and any complications encountered.
- Revenue Code: P1A (MAJOR PROCEDURE - BREAST)
- Payment Status: Active
- Specialties:Plastic Surgery, Reconstructive Surgery
- Place of Service:Ambulatory Surgical Center, Hospital - Inpatient, Hospital - Outpatient