Summary & Overview
CPT 19304: Subcutaneous Mastectomy Surgery
CPT code 19304 is designated for subcutaneous mastectomy, a surgical procedure that removes breast tissue while preserving the skin and nipple. This code is widely used in the management of breast cancer and for risk-reducing surgeries in patients with elevated genetic or familial risk. The procedure is typically performed in outpatient hospital settings, reflecting advances in surgical techniques and patient care.
Key payers covered in this analysis include Blue Cross Blue Shield and Cigna Health, both of which play a significant role in national coverage and reimbursement policies for surgical breast procedures. Readers will gain insight into clinical indications, relevant ICD-10 diagnoses, and associated billing modifiers for 19304. The publication also highlights related CPT codes for mastectomy and breast reconstruction, providing context for coding and policy updates.
This summary offers a comprehensive overview of benchmarks, payer coverage, and clinical context for subcutaneous mastectomy. It is intended for healthcare professionals, policy analysts, and billing specialists seeking clarity on coding practices, payer requirements, and the evolving landscape of breast surgery reimbursement.
CPT Code Overview
CPT code 19304 represents a subcutaneous mastectomy, a surgical procedure involving the removal of breast tissue while preserving the skin and, typically, the nipple. This procedure is commonly performed for both therapeutic and preventive reasons, such as treatment of breast cancer or risk reduction in high-risk patients. The service type is surgery, and the typical site of service is an outpatient hospital setting (Place of Service 22). Subcutaneous mastectomy is a significant intervention in breast health management, offering patients options for both oncologic and reconstructive outcomes.
Clinical & Coding Specifications
Clinical Context
A typical patient scenario involves a female patient diagnosed with a breast condition such as a malignant neoplasm, carcinoma in situ, or an unspecified lump in the breast. The patient is scheduled for a subcutaneous mastectomy (19304) in an outpatient hospital setting. The clinical workflow includes preoperative assessment, surgical removal of breast tissue while preserving the skin and nipple, and postoperative care. The procedure is often performed by a surgery physician, plastic surgeon, or dermatologist, depending on the clinical indication and patient needs.
Coding Specifications
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Modifiers:
50- Bilateral Procedure: Used when the mastectomy is performed on both breasts during the same operative session.LT- Left Side: Indicates the procedure was performed on the left breast.RT- Right Side: Indicates the procedure was performed on the right breast.59- Distinct Procedural Service: Used when the mastectomy is performed as a distinct service from other procedures.
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Provider Taxonomies:
| Taxonomy Code | Specialty |
|---|---|
208600000X | Surgery Physician |
208200000X | Plastic Surgery Physician |
207N00000X | Dermatology Physician |
These taxonomies represent the specialties typically performing or involved in the procedure.
Related Diagnoses
C50.911- Malignant neoplasm of unspecified site of right female breast- Relevant for patients undergoing mastectomy due to cancer in the right breast.
C50.912- Malignant neoplasm of unspecified site of left female breast- Used when the mastectomy is performed for cancer in the left breast.
D05.10- Carcinoma in situ of unspecified breast- Indicates a non-invasive cancer, which may warrant a subcutaneous mastectomy.
N63- Unspecified lump in breast- Used for patients with a breast lump where malignancy cannot be ruled out, justifying surgical intervention.
Z85.3- Personal history of malignant neoplasm of breast- Applied for patients with a history of breast cancer, possibly undergoing prophylactic mastectomy.
Related CPT Codes
19303- Mastectomy, simple, complete: This code represents a more extensive mastectomy procedure and may be used as an alternative to19304depending on clinical indications.19307- Mastectomy, modified radical: Used for cases requiring removal of additional tissue and lymph nodes; may be an alternative or performed in more advanced disease.19340- Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction: Often used in conjunction with19304when immediate breast reconstruction is planned.19357- Breast reconstruction, immediate or delayed, with tissue expander: May be used alongside19304for patients undergoing staged breast reconstruction.
Codes 19340 and 19357 are commonly used together with 19304 in workflows involving immediate or delayed breast reconstruction. Codes 19303 and 19307 are alternatives based on the extent of surgery required.
National Reimbursement Benchmarks
National mean rates for CPT code 19304 show that Blue Cross Blue Shield averages $1,030.87, Cigna averages $1,478.18, and BUCA (the commercial average) stands at $1,335.64. Medicare rates are not available in the input, so a comparison to Medicare is not possible.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, is widest for Cigna ($896.00), followed by BUCA ($626.50), and tightest for Blue Cross Blue Shield ($510.00). This indicates that Cigna's rates vary more significantly across providers nationally, while Blue Cross Blue Shield's rates are more consistent.
The table and chart below present the full breakdown of national benchmarks for each payer.
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