Are coding errors affecting your mastectomy claims? Take a closer look at CPT code 19303! Although mastectomies are relatively common, with over 100,000 women undergoing some form of breast removal surgery each year, they are one of the most frequently miscoded procedures.
Curious about the primary reason? Coding confusion! Many oncologists and coders misapply mastectomy codes due to limited coding knowledge. As a result, they experience a wave of claim denials, payment delays, and compliance risks.
Are you also unaware of CPT 19303’s coding guidelines? Read on to learn everything about this total mastectomy code.
CPT Code 19303 – Description
So, what type of mastectomy does CPT code 19303 cover? Simply put, this code refers to a total mastectomy. To go into more detail, this code describes the surgical removal of the entire breast. This includes:
- The entire breast tissue
- The nipple
- The areola and the surrounding skin
Oncologists perform this procedure for two reasons: to treat or prevent breast cancer. However, you must keep one thing in mind about CPT code 19303. This code only specifies a surgical procedure for removing the breast. It does not cover the removal of underarm lymph nodes or the nearby muscles (pectoralis major and minor).
Scenarios Where CPT Code 19303 is Applicable
Want to avoid coding mistakes for a total mastectomy? Explore the following scenarios to understand the correct application of CPT code 19303:
Invasive Ductal Carcinoma in a Male Patient
Some breast cancers are more common than others. Among them, invasive ductal carcinoma (IDC) affects more women than any other type, accounting for nearly 80% of all breast cancer cases. But did you know it is also one of the most common breast cancers in men?
So, for our first scenario, consider a 61-year-old man with Stage I IDC in his left breast. He arrives at the hospital after noticing a painless lump on his chest. The oncologist evaluates his symptoms and performs a series of diagnostic tests, including imaging studies, to confirm the diagnosis.
Since men have less breast tissue, the surgeon performs a total mastectomy to remove the tumor. He then bills the procedure accurately using CPT code 19303.
Prophylactic Mastectomy to Reduce Breast Cancer Risk
Since CPT code 19303 also applies to prophylactic (preventive) mastectomies, let’s consider the following example:
Suppose a 45-year-old woman with a strong family history of breast cancer undergoes routine screening. Although her results show no signs of cancer, she tests positive for a BRCA1 gene mutation. This puts her at a high risk of developing breast cancer.
She chooses to undergo a prophylactic mastectomy following her physician’s recommendation. The surgeon removes both of her breasts entirely to reduce the risk of future cancer. The billing team then uses CPT code 19303 with modifier 50 to report the bilateral procedure.
Recurrent Invasive Lobular Carcinoma
Did you know invasive lobular carcinoma (ILC), a type of cancer that begins in the milk-producing glands, makes up 10 to 15% of all breast cancer cases? This cancer often recurs and spreads to other parts of the body.
So, for our final example, let us assume a 65-year-old woman experiences a recurrence of ILC in her right breast. To shed some light on her history, she had previously undergone a lumpectomy for the same condition. Hence, the oncologist cannot perform the same procedure again.
As a result, the surgeon removes her entire right breast along with the nipple-areolar complex. He then reports the surgery with CPT code 19303.
Applicable Modifiers for CPT Code 19303
You must specify which breast you removed while using CPT code 19303. Want to know how? Use the following laterality modifiers with this code:
Modifier RT
If you have completely removed the right breast, use modifier RT with CPT code 19303.
Modifier LT
Did you perform a mastectomy on the left breast? Apply modifier LT to CPT code 19303.
Modifier 50
Health providers often perform total mastectomies, especially prophylactic mastectomies, on both breasts. So, how do you report a double mastectomy performed during the same session? The answer is quite simple!
If you have surgically removed both breasts of a patient within the same operative session, append modifier 50 to CPT code 19303.
Besides laterality, you can apply the following modifiers to code 19303, depending on the situation:
Modifier 22
Did you perform additional steps during the mastectomy? You can append modifier 22 to report additional procedural services. For example, you can append this modifier to the CPT code 19303 if you performed the contouring work during initial breast removal surgery.
Modifier 59
Was the breast removal surgery distinct from other services you performed on the same day? Communicate this information to the appropriate payer with modifier 59. However, keep in mind that insurance companies often scrutinize this two-digit code.
Therefore, we recommend using X{EPSU} modifiers instead of modifier 59 whenever possible.
CPT Code 19303 – Billing & Reimbursement Guidelines
Let’s address the most important question: how to bill CPT code 19303 correctly? You can follow these tips to get payers on your side:
Verify & Justify Medical Necessity
Mastectomy should be medically necessary. Therefore, verify the patient’s symptoms before performing this procedure. We all know that insurance companies require justification for complex surgeries. You can do that by submitting complete documentation when filing a claim for CPT code 19303.
Your documentation should include the following details:
- Patient’s condition
- Appropriate ICD-10 code supporting the diagnosis (D05.11 for IDC in the right breast, D05.112 for IDC in the left breast, D05. 0 for lobular carcinoma)
- Reason for performing the complete breast removal surgery
- Anatomical site (left or right breast or both)
- Details about the procedure
Understand the Description of Code 19303
Let us restate that CPT code 19303 covers the complete removal of a breast (total mastectomy). Therefore, don’t confuse this code with those covering partial breast removal surgeries (CPT code 19302) or radical mastectomies (CPT code 19305).
Use this code only when you have removed an entire breast, including the nipple, areola, and the surrounding skin.
Avoid Unbundling
CPT code 19303 refers to a major surgery with a 90-day global period. Hence, this code covers all the pre-, intra-, and post-operative mastectomy services. Therefore, you don’t need separate codes to bill for those services.
Use Laterality Modifiers
If the procedure is unilateral (performed on one side), use either RT or LT modifier with code 19303. But if you have performed a double mastectomy (bilateral breast removal surgery), append modifier 50 to CPT code 19303.
As mentioned in the modifier section, you can also use other supportive modifiers, such as 22 or 59, to communicate additional information.
Comply with Payer Requirements
The best way to avoid billing issues and legal audits is by complying with payer-specific rules. Therefore, review each insurance company’s policy for mastectomy and verify prior authorization requirements.
For example, Medicare generally covers a medically necessary breast removal surgery.
Summary
We hope you no longer confuse CPT code 19303 with other types of mastectomies and their corresponding codes (19301, 19302, and so on). A quick recap! 19303 refers to a total mastectomy, complete removal of a breast. This surgery can either be preventive (to reduce the risk of breast cancer) or treatment-related.
To clear up your confusion, we have discussed all the important aspects of CPT code 19303, including its description and modifier usage. Additionally, we have provided three applicable scenarios of this code so you can learn to use it correctly. If that’s not enough, you can follow our billing tips to avoid denials. But we understand how overwhelming coding can be. So, if you need help, you can always choose reliable oncology billing services.
