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Mastectomy Procedure: An Overview and Coding guideline


Mastectomy is the removal of the whole breast. Mastectomies are primarily performed to remove or prevent breast cancer.

Why do we perform Mastectomy?

Mastectomies are used for Following cancerous and non cancerous conditions :

Types of mastectomy

Total (simple) mastectomy 

Note: A simple or total mastectomy is appropriate for women with multiple or large areas of ductal carcinoma in situ (DCIS) and for women seeking prophylactic mastectomies — that is, breast removal in order to prevent any possibility of breast cancer occurring.

Double mastectomy

Both breasts are removed as a preventive measure; this is often used for high-risk patients who have specific genetic markers that make breast cancer more likely.

Radical mastectomy 

The entire breast, underarm lymph nodes, and chest wall muscles are removed.

Note: Radical mastectomy is recommended only when the breast cancer has spread to the chest muscles under the breast. Radical mastectomy is now rarely performed because in most cases, modified radical mastectomy has proven to be effective.

Modified radical mastectomy 

The entire breast and underarm lymph nodes are removed, but the chest wall muscles are left intact.

Note: People with invasive breast cancer who decide to have mastectomies will receive modified radical mastectomies so that the lymph nodes can be examined. Examining the lymph nodes helps to identify whether cancer cells may have spread beyond the breast.

Skin-sparing mastectomy

The breast tissue and nipple are removed, but the skin is left to reconstruct the breast in the same operation.

Nipple-sparing mastectomy 

During nipple-sparing mastectomy, all of the breast tissue is removed, but the nipple is left alone.

Mastectomy with and without breast reconstruction

Breast prosthesis

If patient don’t want to have reconstruction, Then breast prosthesis is better option. This is a breast form made of silicone gel, foam or other materials that is fitted to chest.

Coding Guidelines

The pivot of coding mastectomy procedures is the amount of tissue removed and any other tissue that may be removed along with breast tissue.

 Mastectomy for gynecomastia — This procedure is performed for treatment of gynecomastia. Gynecomastia is an abnormal condition of large breasts in males. In this procedure, the excess breast tissue is removed. Use code 19300 to report mastectomy for gynecomastia. This is a gender specific code and should be coded for male patients only.

 Partial Mastectomy – also known as lumpectomy, tylectomy, quadrantectomy and segmentectomy.

  1. If the procedure is performed without axillary lymphadenectomy, then report with code 19301.
  2. If the axillary lymph nodes are removed along with the tumor, adequate normal breast tissue around the tumor, skin and lining of chest muscle then report with code 19302. .Do not report 19302 for removal of a few nodes. Further, code 19302 involves removal of lymph node between the pectoralis major and pectoralis minor muscles and axillary nodes.

 Simple Complete Mastectomy —  Total mastectomy, this procedure involves removal of entire breast tissue, leaving the lymph nodes and surrounding muscle intact. Report with code 19303 for a simple total/complete mastectomy.

 Subcutaneous Mastectomy — Also called nipple sparing mastectomy. As the name suggests, this procedure involves removal of the entire breast tissue under the skin. The nipple and overlying skin is left intact. Report with code 19304 for a subcutaneous mastectomy.

 Radical Mastectomy 

  1. Removal of entire breast tissue, axillary lymph nodes, pectoral muscle and surrounding fatty tissue. Report with code 19305 for radical mastectomy including pectoral muscle and axillary lymph nodes.
  2. Removal of entire breast tissue, skin, axillary lymph nodes, internal mammary nodes and pectoral muscle. This type of mastectomy is also referred to as Urban operation. Report with code 19306 for radical mastectomy including pectoral muscle, axillary and internal mammary lymph nodes.

 Modified Radical Mastectomy — This procedure involves removal of entire breast tissue (skin, areola, nipple), and axillary lymph nodes. The pectoralis minor muscle may or may not be removed; however, the pectoralis major muscle is not removed. Report with code 19307 for modified radical mastectomy including axillary lymph nodes, with or without pectoralis minor muscle but excluding pectoralis major muscle.

 Important Point

Example: A patient undergoes partial mastectomy of right breast for treatment of localized lesion suspected to be malignant. The physician removes three superficial sentinel nodes using an open approach. In this case, codes 19301- RT and 38500 should be reported for right partial mastectomy and removal of superficial sentinel nodes respectively.

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