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2025 CPT code 19306

Radical mastectomy, including pectoral muscles, axillary and internal mammary lymph nodes (Urban-type operation).

Consult the most recent CPT manual for accurate coding guidelines.Specific coding guidelines for mastectomies may include instructions on appropriate modifier use, documentation requirements, and considerations for bilateral procedures.

Modifiers 50 (bilateral procedure) and 59 (distinct procedural service) are commonly used with code 19306.Modifier 50 is appropriate for bilateral radical mastectomies. Modifier 59 may be used when the mastectomies performed on each side are different.Other modifiers may be used as clinically appropriate.

Medical necessity for a radical mastectomy (19306) is established when a patient has breast cancer that requires extensive surgical removal of the breast tissue, pectoral muscles, and regional lymph nodes to achieve local control of the disease. The decision to perform this procedure is based on the tumor's size, location, lymph node involvement, and the patient's overall health status.Payer-specific guidelines may influence the determination of medical necessity.

The clinical responsibility lies with the surgeon. This includes pre-operative evaluation, surgical procedure, and post-operative care. The surgeon is responsible for assessing the extent of the disease and selecting the appropriate surgical technique.

IMPORTANT:For radical mastectomy with pectoral muscle and axillary lymph node excision but without internal mammary lymph nodes, see 19305. For modified radical mastectomy (axillary lymph node excision, with or without pectoralis minor muscle, excluding pectoralis major), see 19307.For bilateral procedures using codes 19300, 19301, 19302, 19303, 19305, 19306, 19307, use modifier 50.If bilateral procedures are different (e.g., simple mastectomy on one side and modified radical on the other), use modifier 59 on the second code.

In simple words: The surgeon removes the entire breast, nipple, and surrounding skin, along with chest muscles and nearby lymph nodes. This is a major surgery to remove breast cancer, and it may involve additional procedures like skin grafts or breast reconstruction.

This procedure involves the complete removal of the ipsilateral breast tissue, including the nipple and areola, pectoral muscles, axillary lymph nodes, and internal mammary lymph nodes.It's considered an Urban-type radical mastectomy. The surgical approach includes an elliptical incision to remove all breast tissue, followed by electrocautery to control bleeding.Post-operative considerations may include skin grafts, flaps, or separate breast reconstruction procedures/prosthesis placement. A suction drain is typically placed, and the incision is closed without tension.

Example 1: A 55-year-old female patient diagnosed with invasive ductal carcinoma in the right breast, with lymph node involvement, undergoes a radical mastectomy (19306) to remove the cancerous tissue and regional lymph nodes. Post-operatively, she receives adjuvant chemotherapy and radiation., A 48-year-old female patient with a family history of breast cancer and a high risk of developing the disease opts for a prophylactic bilateral radical mastectomy (19306 with modifier 50). The procedure involves removing both breasts, pectoral muscles, and associated lymph nodes to minimize the risk of future cancer development., A 62-year-old female patient presents with locally advanced breast cancer requiring a radical mastectomy (19306) involving extensive resection of the breast tissue, chest muscles, and lymph nodes.Due to the extent of the surgery, she may need additional reconstructive surgery and prolonged post-operative care.

Detailed pathology report confirming the diagnosis of breast cancer.Preoperative imaging studies (mammography, ultrasound, MRI) demonstrating the extent of the tumor and lymph node involvement. Intraoperative findings documenting complete removal of the breast tissue, pectoral muscles, axillary, and internal mammary lymph nodes. Postoperative pathology report confirming clear surgical margins and the extent of lymph node dissection.Surgical notes detailing the surgical technique and any complications encountered.Physician orders for post-operative care, including pain management, wound care, and adjuvant therapies.

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

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