In simple words: The surgeon removes the entire breast, including the nipple and skin, but leaves the chest muscles and lymph nodes in the armpit untouched. This is done to treat or prevent breast cancer.

A simple mastectomy involves the complete removal of the ipsilateral breast tissue, including the nipple-areolar complex and the overlying skin.The pectoralis major and minor muscles, as well as the axillary lymph nodes, are left intact.The procedure typically includes an elliptical incision around the nipple-areolar complex, dissection through subcutaneous tissue, and removal of breast tissue from the chest wall down to the pectoralis major and latissimus dorsi muscles. Hemostasis is achieved through coagulation of blood vessels. A drain may be placed to remove excess fluid, and the incision is closed without tension.

Example 1: A 45-year-old female diagnosed with invasive ductal carcinoma in the upper outer quadrant of the right breast undergoes a right simple mastectomy.Sentinel lymph node biopsy is performed separately., A 60-year-old female with a strong family history of breast cancer elects for a prophylactic bilateral simple mastectomy.This procedure is performed on both breasts with the addition of modifier 50., A 38-year-old female withductal carcinoma in situ (DCIS) in the left breast undergoes a left simple mastectomy with immediate breast reconstruction. This is coded as 19303 and the reconstruction codes are billed separately.

Detailed pathology report confirming the diagnosis, surgical notes outlining the procedure performed including details about tissue resection and hemostasis, imaging studies showing the location and extent of the tumor (if applicable), and any post-operative complications or follow-up care.

** Intraoperative placement of clips is not separately reported. For immediate or delayed insertion of an implant, use codes 19340 or 19342.