Capsulectomy with Breast Reconstruction Implant Exchange

Question:

We billed 19371 (capsulectomy) with a breast reconstruction implant exchange (19342 – larger to smaller). We were denied 19371. Should we have used modifier 59 on 19371 to get paid?

Answer:

This Medicare National Correct Coding Initiative (NCCI) edit is a dilemma. CPT implies that you are allowed to use both codes – 19342 and 19371 (or even 19342 and 19370) – but Medicare won’t pay both codes. It would not be accurate to bypass the NCCI edit with modifier 59 when the procedures are performed on the same side. Modifier 59 may be used when the procedures are performed on different sides.