CPT 19300 Mastectomy for Gynecomastia Reimbursement | OpenPayer

Summary & Overview

CPT 19300: Mastectomy for Gynecomastia

Headline: CPT 19300 — Mastectomy for Gynecomastia, Outpatient Surgical Procedure

Lead: CPT 19300 identifies mastectomy performed to treat gynecomastia, a common surgical approach to removing excess male breast tissue. The code captures a distinct outpatient mastectomy procedure that has implications for coverage, billing, and clinical documentation across major payers.

Overview: Nationally, CPT 19300 represents a targeted surgical intervention within plastic and reconstructive surgery and related specialties. It is relevant for surgeons, hospital billing teams, and payers because proper coding supports accurate claims processing, medical necessity review, and care continuity for patients seeking correction of gynecomastia. Key payers evaluated include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.

What readers will learn: This publication provides benchmarks for utilization and common billing practices, summarizes payer coverage contexts and authorization considerations, and outlines clinical context for the procedure. It highlights procedural scope and typical outpatient delivery, identifies common billing modifiers and related procedural codes, and lists relevant ICD-10 diagnoses associated with gynecomastia. Where specific operational data or service-line metadata are missing, the text notes "Data not available in the input."

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareCPT 19300Mastectomy ProceduresGynecomastiaOutpatient SurgeryPlastic SurgerySurgical CodingBilling ModifiersICD-10

CPT Code Overview

CPT 19300 describes mastectomy for gynecomastia, a surgical procedure to remove excess breast tissue in males. This procedure falls under the Mastectomy Procedures service type and is most commonly performed in an Outpatient Hospital (POS 22) setting. The code is used to document definitive surgical treatment for gynecomastia when tissue excision is indicated.

Clinical & Coding Specifications

Clinical Context

A 28-year-old male presents to an outpatient hospital surgical clinic with unilateral enlargement of the male breast and tenderness. Clinical evaluation and history identify persistent gynecomastia despite conservative measures and trial of medical therapy. Imaging (ultrasound or mammography as indicated) excludes a suspicious mass. The patient elects surgical management and is scheduled for 19300 (mastectomy for gynecomastia) in an outpatient hospital setting (POS 22). Preoperative evaluation includes medical clearance by primary care (Family Medicine or Internal Medicine), laboratory assessment as indicated for comorbid conditions (for example hypothyroidism or hypopituitarism), and perioperative planning with the operating surgeon (Plastic and Reconstructive Surgery or Plastic Surgery). On the day of service, the procedure is performed under appropriate anesthesia, and documentation includes laterality, extent of tissue removal, intraoperative findings, and any concurrent procedures. Postoperative follow-up is arranged in the surgeon’s clinic with wound checks and instructions for activity restrictions and follow-up for underlying endocrine or metabolic conditions as indicated.

Coding Specifications

Modifiers
50 - Bilateral Procedure: Use when mastectomy for gynecomastia is performed on both sides during the same operative session.
LT - Left Side: Use when the procedure is performed only on the left breast. Documentation must clearly support laterality.
RT - Right Side: Use when the procedure is performed only on the right breast. Documentation must clearly support laterality.

National Reimbursement Benchmarks

Medicare's national mean allowed rate of $656.74 is slightly below the BUCA (average commercial) mean of $681.62 for CPT 19300, indicating commercial payers on average reimburse a bit higher than Medicare. The absolute difference between Medicare and the BUCA commercial benchmark is $24.89.

Dispersion (P75 − P25) varies notably across payers. UnitedHealth Group shows the widest spread at $529.33 (P75 $1,054.33 − P25 $525.00), followed by Cigna at $482.25. Aetna is among the tightest with a spread of $148.71, and Medicare is also tight at $71.00. The table and chart below present the full percentile and mean breakdown for each national payer.

State Benchmarks

State: Alaska1 / 50

Alaska Benchmarks

Alaska exhibits a wide spread in reimbursement rates for CPT code 19300, with the highest payer (Aetna) offering a mean rate of $2,123.70 and the lowest (Medicare) at $635.81. The rate spread, calculated as the difference between the 75th and 25th percentiles, is most pronounced for Blue Cross Blue Shield ($829.08) and BUCA ($749.96), indicating substantial variability among commercial payers. In contrast, Aetna's percentiles are tightly clustered, suggesting consistent rates across providers.

Compared to national averages, all commercial payers in Alaska reimburse at rates well above their national benchmarks, with Aetna's mean rate nearly four times the national mean. The table and chart below present the full breakdown of payer-specific rates and percentiles for Alaska.

Key Insights for Alaska

Aetna is the highest paying payer for CPT 19300 in Alaska, with a mean rate of $2,123.70.
Medicare is the lowest paying payer, with a mean rate of $635.81.
All commercial payers in Alaska reimburse at rates significantly above their respective national averages, with Aetna's mean rate nearly four times the national mean.

CPT 19306: Radical Mastectomy with Chest Wall and Lymphadenectomy

19302-MASTECTOMY-PARTIAL-EG-LUMPECTOMY-TYLECTOMY-QUADRANTECTOMY

CPT 19302: Partial Mastectomy with Axillary Lymphadenectomy

19303-MASTECTOMY-SIMPLE

CPT 19303: Simple, Complete Mastectomy Procedure

19305-RADICAL

CPT 19305: Radical Mastectomy Surgery

19301-MASTECTOMY-PARTIAL-EG-LUMPECTOMY-TYLECTOMY-QUADRANTECTOMY

CPT 19301: Partial Mastectomy (Lumpectomy)

CPT-19307-MASTECTOMY-REMOVAL-ENTIRE-BREAST

CPT 19307: Mastectomy, Removal of Entire Breast

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