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2025 CPT code 19300

Mastectomy for gynecomastia.

Modifier 50 should be appended for bilateral procedures.It’s crucial to differentiate this procedure from breast reduction procedures performed for cosmetic reasons (19318) or mastectomies performed to treat or prevent breast cancer (19301-19307).

Modifiers such as 22 (Increased Procedural Services), 50 (Bilateral Procedure), 52 (Reduced Services), 53 (Discontinued Procedure), etc. may be applicable depending on the specific circumstances of the procedure.

Medical necessity for this procedure must be established by documenting the patient's symptoms, the failure of conservative treatment options, and the impact of gynecomastia on the patient's physical or psychological well-being.Documentation might include the presence of pain, infection, or significant emotional distress related to the condition.

The surgeon is responsible for performing the mastectomy, including pre-operative evaluation, the surgical procedure itself, and post-operative care.This procedure is performed on male patients only.

IMPORTANT:For breast tissue removed for breast-size reduction for other than gynecomastia, use 19318.

In simple words: This procedure removes excess breast tissue in men due to a condition called gynecomastia. The surgeon makes an incision, removes the extra tissue, and closes the incision. Sometimes, a drain is placed to remove excess fluid.

This code describes a mastectomy performed to treat gynecomastia (excessive enlargement of the male breast). The procedure involves the surgical removal of breast tissue, skin, and sometimes fat from the male breast.It may involve a portion of the breast or the entire breast.This code is not used for female patients or for breast reduction procedures not related to gynecomastia.

Example 1: A 25-year-old male patient presents with bilateral gynecomastia, causing emotional distress and impacting his self-esteem.The surgeon performs a bilateral mastectomy using code 19300 with modifier 50., A 40-year-old male has unilateral gynecomastia due to a hormonal imbalance.The surgeon performs a mastectomy on the affected side using code 19300., A teenager experiences pubertal gynecomastia that does not resolve on its own.After observation and medical management, surgical intervention is deemed necessary, and code 19300 is used.

Documentation should include the diagnosis of gynecomastia, the surgical technique used, the size and location of the incision, whether a drain was placed, and any complications encountered. Pre- and post-operative photographs are also helpful.A detailed operative report and informed consent form are imperative.

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