Summary & Overview
CPT 19303: Simple, Complete Mastectomy Procedure
CPT code 19303 represents a simple, complete mastectomy, a critical surgical intervention for patients with breast cancer and other serious breast conditions. This procedure is widely performed across the United States and is a cornerstone of breast cancer treatment protocols. The code is recognized by major national payers, including Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare, ensuring broad coverage and reimbursement for providers and facilities.
This publication provides a comprehensive overview of CPT code 19303, including its clinical context, typical site of service, and payer coverage. Readers will gain insights into national benchmarks, policy updates, and the procedural landscape for mastectomy services. The analysis also highlights relevant modifiers, associated taxonomies, and common ICD-10 diagnoses linked to this code, offering a clear understanding of its role in surgical oncology and breast health management. By examining payer policies and clinical guidelines, the article equips stakeholders with essential information for navigating the complexities of medical billing and coding for mastectomy procedures.
CPT Code Overview
CPT code 19303 describes a simple, complete mastectomy, a surgical procedure involving the removal of all breast tissue without axillary lymph node dissection. This procedure is typically performed for patients with breast cancer or other significant breast conditions. The service type is Surgical – Mastectomy Procedures, and the most common site of service is the inpatient hospital setting (Place of Service 21). This code is central to surgical oncology and breast surgery practices nationwide.
Clinical & Coding Specifications
Clinical Context
A typical patient scenario involves an adult female diagnosed with breast cancer or a suspicious breast lesion. The patient is admitted to an inpatient hospital setting for a surgical procedure. The clinical workflow includes preoperative assessment, imaging, and consultation with a surgical oncologist or general surgeon. The procedure performed is a simple, complete mastectomy (19303), which entails removal of all breast tissue without axillary lymph node dissection. Postoperative care includes monitoring for complications, pain management, and coordination with oncology for further treatment if indicated.
Coding Specifications
| Modifier Code | Description | Usage Scenario |
|---|---|
| RT | Right side | Used when the mastectomy is performed on the right breast |
| LT | Left side | Used when the mastectomy is performed on the left breast |
| 50 | Bilateral procedure | Used when mastectomy is performed on both breasts during the same operative session |
| 59 | Distinct procedural service | Used when a distinct or separate mastectomy procedure is performed, not normally reported together |
Associated Provider Taxonomies:
208600000X– Surgery Physician (General Surgery)2086S0122X– Surgical Oncology Physician (Surgical Oncology)208800000X– Plastic Surgery Physician (Plastic Surgery)207N00000X– Dermatology Physician (Dermatology)
These taxonomies represent the specialties typically involved in performing or assisting with mastectomy procedures.
Related Diagnoses
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C50.911– Malignant neoplasm of unspecified site of right female breast- Indicates breast cancer located in the right breast, justifying the need for a mastectomy.
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C50.912– Malignant neoplasm of unspecified site of left female breast- Indicates breast cancer located in the left breast, supporting mastectomy of the left breast.
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D05.10– Carcinoma in situ of unspecified breast- Represents non-invasive breast cancer, which may require mastectomy depending on clinical factors.
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Z85.3– Personal history of malignant neoplasm of breast- Used for patients with a history of breast cancer, possibly undergoing prophylactic mastectomy.
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N63– Unspecified lump in breast- Indicates a breast lump of unknown etiology, which may warrant mastectomy if malignancy cannot be ruled out.
Related CPT Codes
19307– Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle
19307 is related to 19303 as a more extensive surgical procedure. While 19303 involves removal of breast tissue only, 19307 includes axillary lymph node dissection. 19307 may be used as an alternative when lymph node removal is clinically indicated. These codes are not typically billed together for the same breast in a single operative session.
National Reimbursement Benchmarks
National mean rates for CPT code 19303 show that Medicare reimbursement is significantly lower than the commercial average, with Medicare at $925.57 compared to the BUCA mean rate of $1,285.11. Among commercial payers, UnitedHealth Group has the highest mean rate at $1,627.86, while Blue Cross Blue Shield is the lowest at $1,090.98.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies notably across payers. Blue Cross Blue Shield exhibits the tightest range ($619.80), while UnitedHealth Group has the widest ($984.00), indicating greater variability in commercial rates. Cigna and Aetna also show substantial dispersion, with ranges of $889.50 and $570.25, respectively. Medicare's range is the narrowest at $76.00, reflecting more consistent rates.
The table and chart below present a detailed breakdown of national benchmarks for each payer, including mean rates and percentile values.
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