Tissue expander exchange

A patient presented seven weeks status post first stage bilateral pre-pectoral breast expander-implant reconstruction. Fluid collection had developed along the incision on the right breast with thinning of the skin so that the expander could be visualized, requiring treatment to prevent implant exposure and infection. The skin was incised, implant pocket was entered and the expander removed. Acellular dermal matrix, was removed from the breast skin and subcutaneous fat and the implant pocket was debrided. A new expander was placed in the pocket with replacement of acellular dermal matrix. Is CPT code 19371 or 19357 the correct code to capture debridement of the implant pocket with removal and replacement of tissue expanders with dermal graft? ...

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Note:  The following article synopsis was NOT provided by the AHA. It was created by Find-A-Code/innoviHealth.

Article Overview

This article addresses coding for a breast reconstruction scenario in which an existing breast tissue expander is removed and replaced, with associated pocket work and dermal matrix management. It is intended for coders, billers, and clinicians working in breast reconstruction and related surgical coding, and it focuses on how to think about CPT code selection for this type of operative service.

Why This Topic Matters

Accurate CPT selection is important for capturing the surgical work performed in breast reconstruction procedures and for avoiding misclassification of related operative services.

What You Will Learn

  • How a breast reconstruction tissue expander exchange case is framed for coding review
  • Which CPT code set is relevant to this type of procedure
  • How the article approaches comparison of related reconstructive breast surgery codes at a high level
  • The role of pocket work and dermal matrix management in the coding discussion

Who Should Read This

  • Medical coders
  • Billing staff
  • Plastic and reconstructive surgery practices
  • Revenue cycle teams

Codes Discussed


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