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: