Summary & Overview
CPT 19305: Radical Mastectomy Surgery
CPT code 19305 is designated for radical mastectomy, a comprehensive surgical procedure used in the treatment of advanced breast cancer. This code is nationally recognized and plays a critical role in both clinical care and medical billing for mastectomy procedures. Radical mastectomy involves the removal of the entire breast, underlying chest wall muscles, and axillary lymph nodes, making it one of the most extensive breast surgeries performed.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare. Understanding how these major insurers approach coverage and reimbursement for CPT code 19305 is essential for healthcare organizations, clinicians, and policy analysts.
Readers will gain insight into the clinical context of radical mastectomy, typical sites of service, and relevant coding benchmarks. The publication also addresses policy updates, common billing modifiers, associated provider taxonomies, and ICD-10 diagnoses linked to this procedure. By reviewing this information, stakeholders can better understand national trends in surgical oncology, coding practices, and payer policies related to radical mastectomy.
CPT Code Overview
CPT code 19305 represents a radical mastectomy, a surgical procedure involving the removal of the entire breast, underlying chest muscles, and lymph nodes in the axilla. This procedure is typically performed for patients with advanced or aggressive breast cancer. The service type is mastectomy procedures, and the most common site of service is the inpatient hospital setting (Place of Service 21). Radical mastectomy is a significant intervention in breast cancer management, often reserved for cases where less extensive surgery is not appropriate.
Clinical & Coding Specifications
Clinical Context
A typical patient scenario involves a female patient diagnosed with breast cancer, such as a malignant neoplasm of the right or left breast. The patient is admitted to an inpatient hospital setting (Place of Service 21) for a radical mastectomy, which is a surgical procedure to remove the entire breast tissue, underlying chest muscles, and lymph nodes. This procedure is performed by a surgeon, surgical oncologist, or plastic surgeon, depending on the clinical situation. The workflow includes preoperative assessment, surgical intervention, and postoperative care, often involving multidisciplinary coordination for optimal outcomes.
Coding Specifications
Common Modifiers:
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Modifier
50: Bilateral Procedure – Used when the radical mastectomy is performed on both breasts during the same operative session. -
Modifier
RT: Right Side – Indicates the procedure was performed on the right breast. -
Modifier
LT: Left Side – Indicates the procedure was performed on the left breast. -
Modifier
22: Increased Procedural Services – Applied when the procedure requires significantly more work than usual due to complexity or complications.
Provider Taxonomies:
| Taxonomy Code | Specialty Name |
|---|---|
208600000X | Surgery Physician |
2086S0122X | Surgical Oncology Physician |
208800000X | Plastic Surgery Physician |
These taxonomies represent providers specializing in general surgery, surgical oncology, and plastic surgery, all of whom may perform radical mastectomy procedures.
Related Diagnoses
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C50.911: Malignant neoplasm of unspecified site of right female breast- Indicates cancer in the right breast, a primary reason for radical mastectomy.
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C50.912: Malignant neoplasm of unspecified site of left female breast- Indicates cancer in the left breast, also a primary indication for radical mastectomy.
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D05.11: Lobular carcinoma in situ of right breast- Represents a non-invasive cancer in the right breast; may warrant mastectomy in certain clinical scenarios.
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D05.12: Lobular carcinoma in situ of left breast- Represents a non-invasive cancer in the left breast; mastectomy may be considered based on risk factors.
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Z85.3: Personal history of malignant neoplasm of breast- Indicates a patient with a history of breast cancer, which may influence surgical decision-making for mastectomy procedures.
Related CPT Codes
| CPT Code | Description | Clinical Relationship |
|---|---|---|
19303 | Mastectomy, simple, complete | Alternative to radical mastectomy; involves removal of breast tissue without extensive lymph node or muscle removal. |
19306 | Data not available in the input. | Data not available in the input. |
19307 | Data not available in the input. | Data not available in the input. |
19303 is commonly used as an alternative to 19305 when less extensive surgery is indicated. Codes 19306 and 19307 are listed as related but lack descriptions in the input, so their clinical relationship cannot be specified.
National Reimbursement Benchmarks
Medicare's national mean rate for CPT code 19305 is $1,109.17, which is notably lower than the BUCA (average commercial) mean rate of $1,499.75. Commercial payers such as UnitedHealth Group and Cigna have even higher mean rates, at $1,914.93 and $1,830.01 respectively, while Blue Cross Blue Shield and Aetna are closer to the BUCA average.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Medicare exhibits the tightest range ($88.00), indicating relatively consistent reimbursement. In contrast, UnitedHealth Group shows the widest dispersion ($1,177.00), followed by Cigna ($1,057.00), reflecting greater variability in commercial rates. Blue Cross Blue Shield and BUCA also display substantial ranges, while Aetna's dispersion is moderate.
The table and chart below present the full breakdown of national benchmarks for CPT code 19305 across major payers.
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