Do you know that breast cancer is the second most common type of cancer in the United States? According to the American Cancer Society, over 316,950 women will be diagnosed with breast cancer in 2025 alone. This is a concern for both the patients and the healthcare providers.
The high number of patients also means billing complexities and payment issues. A standard treatment for early-stage (I and II) breast cancer is a partial mastectomy, which is billed using the CPT code 19301. So, it is vital to understand how to bill it correctly.
That is what this blog is all about. In this guide, we will provide a detailed description of CPT code 19301, the modifiers you can use, and some essential guidelines that you must follow to avoid claim denials. So, let’s start.
CPT Code 19301 – Description
The official definition of CPT code 19301 is:
“Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy).”
Let’s try to break this down in simple wording. Code 19301 represents an oncologic surgical procedure in which a portion of the breast tissue is removed. This is usually done to treat breast cancer or remove benign tumors while preserving as much of the breast as possible.
The word “partial” is significant here. That is because a partial mastectomy (19301) is different from a complete mastectomy (19303) or an excision of a breast lesion (19120). So, what is the difference? Well, unlike a full mastectomy, which removes the entire breast, a partial mastectomy focuses on excising only the affected area (with some margin of healthy tissue).
Please note that this treatment is mostly used to treat early stages of cancer, and in advanced stages, other treatments are more suitable.
Scenarios Where CPT Code 19301 is Applicable
Let’s now look at some real-world scenarios in which CPT code 19301 can be used for medical billing.
Early-Stage Breast Cancer Treatment
As we discussed above, the most evident use of CPT code 19301 is for oncologic surgical procedures to remove the breast tissue partially. Some examples of surgical procedures include:
- Removal of invasive ductal carcinoma (IDC)
- Removal of invasive lobular carcinoma (ILC)
- Excision of ductal carcinoma in situ (DCIS)
Re-excision for Positive Margins
Another scenario in which CPT code 19301 can be used is when, in a previous partial mastectomy surgery, the surgeon was not able to remove the entire cancerous tissue. To rectify this, another surgery is needed, which will then be billed with 19301.
However, to show that this is a planned, related surgery done after the first one, modifier 58 is added. This means the doctor needs to go back in to remove more tissue, and this plan should be noted in the surgery report.
Applicable Modifiers for CPT Code 19301
You may append the following modifiers to code 19301.
| Modifier | Description |
|---|---|
| LT | Indicates the procedure was performed on the left breast. |
| RT | Used when the procedure was performed on the right breast. |
| 50 | Applied when a bilateral procedure is performed. |
| 22 | This modifier is used when a procedure becomes more complex or time-consuming than the standard. |
| 58 | Used for staged or related procedures by the same physician during the postoperative period. |
| 78 | For an unplanned return to the operating room following the initial procedure. |
| GC | This modifier is used to indicate that a resident performed the surgery under the supervision of a senior physician. |
CPT Code 19301 – Billing & Reimbursement Guidelines
For a fair reimbursement and to avoid claim denials, you must be aware of the expected reimbursement amount and follow the guidelines mentioned below:
Documentation Requirements
Documentation is the most essential part of any insurance claim. Surgeons must maintain detailed operative reports to justify the necessity of the medical procedure. For CPT code 19301, the following records are crucial:
- The medical necessity for the procedure
- The specific technique used
- The size and location of the lesion
- Details about the margin tissue
- Any additional tissue removed from the margins
- Pathology report confirming the diagnosis and margin status
- A clear indication of the operated breast (right, left, or bilateral)
Correct Diagnosis Codes
The procedure must be linked to an appropriate ICD-10 diagnosis code. There are tens of different diagnoses that may lead to a mastectomy, reported by CPT code 19301. The following are some valid ICD-10 diagnoses for partial mastectomy:
- C50.011: Cancer of the nipple and areola in the right female breast.
- C50.111: Cancer in the central portion of the right female breast.
- C50.211: Cancer in the upper-inner quadrant of the right breast.
- C50.311: Cancer in the lower-inner quadrant of the right breast.
- C50.411: Cancer in the upper-outer quadrant of the right breast.
- C50.511: Cancer in the lower-outer quadrant of the right female breast.
- C50.611: Cancer in the axillary tail of the right female breast.
- C50.811: Cancer at overlapping sites in the right breast.
- C50.911: Cancer at an unspecified site in the right female breast.
Please note that these are just some of the ICD-10 diagnosis codes that justify a partial mastectomy. These are examples of cancer diagnosis in the right breast, and other similar codes also exist for the left breast, with the third digit changed to “2” (e.g., C50.012 – cancer of nipple and areola, left female breast).
Medicare Reimbursement
The reimbursement amount for CPT code 19301 is dependent on the MAC locality and facility. According to the latest Medicare reimbursement rates, the national average reimbursement amount of 19301 for facility settings is $652.79.
You can check the exact Medicare reimbursement amount for your MAC locality via the PFS Lookup Tool.
Wrapping Up
CPT code 19301 is one of the most frequently used oncology billing codes. By appending the proper documentation and modifiers and following the guidelines mentioned in this blog, you can accurately file claims with code 19301.
However, if you are still facing issues with your billing or want to outsource your non-clinical operations, our consultants are available to offer premium oncology billing services.
