CODING MASTECTOMY PROCEDURES

By Chaitali Goswami, CCS, CPC

OBJECTIVE
The purpose of this article is to enable you to understand and correctly implement the coding principles, concepts, and guidelines associated with various mastectomy procedure codes.

SURGICAL INFORMATION
Mastectomy is the surgical procedure in which the entire breast or part of the breast is removed, usually performed to treat breast cancer. There are various types of mastectomy procedures that can be performed depending on the size of tumor, stage and grade of cancer, hormone receptor status of the tumor, or involvement of lymph node. The age and general health of the patient also affect the choice of surgery.

A patient with a questionable breast lesion undergoes biopsy. On confirmation of cancer, the physician would recommend mastectomy, depending on various factors such as number of tumors, stage of cancer, family history, etc. Many patients at high risk category for breast cancer undergo prophylactic mastectomy. 

CODING AND GUIDELINES INVOLVED

Pivot of Coding
The pivot of coding mastectomy procedures is the amount of tissue removed and any other tissue that may be removed along with breast tissue. As per CPT guidelines, codes 19301 and 19302 are used to report partial mastectomy procedures with clear documentation of attention to removal of adequate surgical margins. Total mastectomy procedures in the CPT codebook include simple mastectomy, complete mastectomy, subcutaneous mastectomy, radical mastectomy, Urban type operation, and modified radical mastectomy.1

The Procedures
Mastectomy for gynecomastia — This procedure is performed for treatment of gynecomastia. Gynecomastia is an abnormal condition of large breasts in males. In this procedure, the excess breast tissue is removed. Use code 19300 to report mastectomy for gynecomastia. This is a gender specific code and should be coded for male patients only. The amount of excision of tissue is based on physician discretion.

Partial Mastectomy — Also called lumpectomy, this procedure involves removal of tumor along with adequate amount of normal breast tissue around the tumor, skin and lining of chest muscle.2

  1. If the procedure is performed without axillary lymphadenectomy, then report with code 19301.
  2. If the axillary lymph nodes are removed along with the tumor, adequate normal breast tissue around the tumor, skin and lining of chest muscle then report with code 19302. Code 19302 is reportable only when a complete axillary dissection is performed.Do not report 19302 for removal of a few nodes. Further, code 19302 involves removal of lymph node between the pectoralis major and pectoralis minor muscles and axillary nodes. All identifiable lymph nodes are removed.3

Simple Complete Mastectomy — Traditional total mastectomy, this procedure involves removal of entire breast tissue, leaving the lymph nodes and surrounding muscle intact. Report with code 19303 for a simple total/complete mastectomy, unless performed for gynecomastia (reported with code 19300)

Subcutaneous Mastectomy — Also called nipple sparing mastectomy. As the name suggests, this procedure involves removal of the entire breast tissue under the skin. The nipple and overlying skin is left intact. Report with code 19304 for a subcutaneous mastectomy

Radical Mastectomy — As the name suggest, radical removal signifies more than just the diseased tissue. This procedure can be performed in the following two ways:

  1. Removal of entire breast tissue, axillary lymph nodes, pectoral muscle and surrounding fatty tissue. Report with code 19305 for radical mastectomy including pectoral muscle and axillary lymph nodes.
  2. Removal of entire breast tissue, skin, axillary lymph nodes, internal mammary nodes and pectoral muscle. This type of mastectomy is also referred to as Urban operation. Report with code 19306 for radical mastectomy including pectoral muscle, axillary and internal mammary lymph nodes.

Radical mastectomy is performed when the cancer invades the chest wall.4 This type of mastectomy is rarely performed these days.

Modified Radical Mastectomy — This procedure is less extensive than radical mastectomy and hence is more commonly performed. This procedure involves removal of entire breast tissue (skin, areola, nipple), and axillary lymph nodes. The pectoralis minor muscle may or may not be removed; however, the pectoralis major muscle is not removed. Report with code 19307 for modified radical mastectomy including axillary lymph nodes, with or without pectoralis minor muscle but excluding pectoralis major muscle.

Important Guidelines

  1. Mastectomy procedures are unilateral procedures. To report bilateral performance, add modifier 50.5

    Example: A 50-year-old patient is found to have malignant lumps in both the breasts. The physician performs bilateral lumpectomy with adequate surgical margins. Frozen section confirms negative margins. In this case, 19301 should be reported with 50 modifier to indicate procedure performed on both breasts.
  1. As per CPT Assistant, codes 38500, Biopsy or excision of lymph node(s); open, superficial and 38525, Biopsy or excision of lymph node(s); open, deep axillary node(s) should be reported for removal/sampling of few sentinel nodes without complete axillary dissection, as appropriate.6

    Example: A patient undergoes partial mastectomy of right breast for treatment of localized lesion suspected to be malignant. The physician removes three superficial sentinel nodes using an open approach. In this case, codes 19301- RT and 38500 should be reported for right partial mastectomy and removal of superficial sentinel nodes respectively.
  1. As per CPT Assistant, reporting of axillary lymph node dissection during partial mastectomy (code 19302) does not depend on the incision made for axillary dissection but the extent of axillary node dissection. Axillary dissection through the same incision as partial mastectomy or through a different incision does not make any difference in the choice of code.7
  2. As per CPT Assistant, placement of fiducial marker is inclusive to code 19301, Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy).8

NOTES

1. American Medical Association. Current Procedural Terminology 2014 Professional Edition. Chicago: IL: American Medical Association, p. 89.  BACK TO TEXT

2. American Medical Association. "Coding Communication: Mastectomy Procedures." CPT Assistant. Chicago, IL: American Medical Association, .February 2007, p. 4-5.  BACK TO TEXT

3. American Medical Association. "Coding Brief: Partial Mastectomy/Lumpectomy and Axillary Lymphadenectomy-19301, 19302, 38500, 38525." CPT Assistant. Chicago, IL: American Medical Association, September 2008 p. 5-6.   BACK TO TEXT

4. CPT Assistant. February 2007 p. 4-5.  BACK TO TEXT

5. Ibid.  BACK TO TEXT

6. Ibid.  BACK TO TEXT

7. CPT. Assistant. September 2008 p. 5-6.  BACK TO TEXT

8. American Medical Association. "Surgery: Integumentary System." CPT Assistant. Chicago, IL: American Medical Association,  November 2013 p. 14.  BACK TO TEXT

 
REFERENCES

American Medical Association. "Coding Communication: Surgery: Integumentary System." CPT Assistant. Chicago, IL: American Medical Association, December 2007, p. 8.

"Mastectomy." Available from the Mayo Clinic website at www.mayoclinic.org/tests-procedures/mastectomy/basics/why-its-done/prc-20012749.

"Mastectomy." Available at MedlinePlus, a service of the National Library of Medicine, National Institutes of Health at www.nlm.nih.gov/medlineplus/mastectomy.html.

Chaitali Goswami, CCS, CPC is coding operations manager at Amura Health Solutions, in San Diego, CA.

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