2025 CPT code 19307
Effective Date: N/A Surgery - Integumentary System Feed
Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle. Intraoperative placement of clip(s) is not separately reported. For immediate or delayed insertion of implant, see 19340, 19342.
Modifiers may be applicable. Modifier 50 is used for bilateral procedures. Modifier 59 is used when a different type of mastectomy is performed on the contralateral breast. Other modifiers may apply depending on the specific circumstances.
Medical necessity for this procedure is established by a diagnosis of breast cancer or prophylactic reasons in high-risk patients. Documentation should clearly link the procedure to the diagnosis and treatment plan.
The surgeon makes an elliptical incision from the inner breast towards the armpit, removes the breast tissue, axillary lymph nodes, and possibly the pectoralis minor muscle. The incision is closed with sutures or staples. The surgeon may also use skin grafts or flaps if needed.
In simple words: This procedure removes all breast tissue and lymph nodes from under the arm on the same side.The smaller chest muscle may be removed, but the larger one is left in place. The nipple may or may not be removed.This procedure is used to treat breast cancer.
Modified radical mastectomy involves removing all breast tissue from the affected breast, including axillary lymph nodes. The procedure may or may not include removal of the pectoralis minor muscle, but the pectoralis major muscle is spared. Skin and/or nipple sparing techniques may be used. This code does not include immediate or delayed insertion of a breast implant (see 19340, 19342) or placement of clips, which are not reported separately.
Example 1: A 55-year-old female is diagnosed with invasive ductal carcinoma and undergoes a modified radical mastectomy with removal of axillary lymph nodes and the pectoralis minor muscle., A 60-year-old female with a strong family history of breast cancer opts for a prophylactic modified radical mastectomy, sparing the nipple and skin, but removing axillary lymph nodes., A 48-year-old female undergoes a modified radical mastectomy with removal of axillary lymph nodes following neoadjuvant chemotherapy for locally advanced breast cancer.
Documentation should include type of mastectomy, extent of lymph node dissection, status of pectoralis muscles, any nipple/skin sparing techniques, and medical necessity for the procedure (diagnosis, staging information, etc.).
- Global Days: 90 days
- Specialties:Surgical Oncology, General Surgery, Plastic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center