© Copyright 2025 American Medical Association. All rights reserved.
A mastectomy for gynecomastia is a surgical procedure aimed at addressing the condition known as gynecomastia, which is characterized by the abnormal enlargement of breast tissue in males. This enlargement can occur in one or both breasts and is often due to an excess of glandular tissue. The procedure involves the excisional removal of this excess breast tissue, which is typically indicated for patients who have significant amounts of glandular tissue that may cause discomfort or psychological distress. During the surgery, an incision is strategically made at the base of the areola, which is the pigmented area surrounding the nipple. In cases where there is a substantial amount of breast tissue to be removed, the incision may be extended into the inframammary fold, which is the crease beneath the breast. The surgeon carefully dissects the excess tissue from the underlying pectoral muscle and excises it, ensuring that any excess skin is also removed to achieve a more contoured appearance. After the removal of the tissue, the incision is closed, and in some instances, a drain may be placed through a separate incision to facilitate the drainage of any fluid that may accumulate post-operatively. Finally, the chest area is wrapped to provide necessary compression to the surgical site, aiding in the healing process and minimizing swelling.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure of mastectomy for gynecomastia is indicated for patients presenting with the following conditions:
The mastectomy for gynecomastia involves several key procedural steps that are performed to ensure the effective removal of excess breast tissue:
After the mastectomy for gynecomastia, patients can expect specific post-procedure care and considerations. It is common for patients to experience some swelling and discomfort in the chest area, which can be managed with prescribed pain medications. The surgical site should be monitored for any signs of infection, such as increased redness, swelling, or discharge. Patients are typically advised to avoid strenuous activities and heavy lifting for a specified period to allow for proper healing. Follow-up appointments are essential to assess the surgical site, remove any drains if placed, and ensure that the recovery is progressing as expected. Additionally, patients may receive guidance on scar management and any necessary lifestyle modifications to support their overall health and well-being following the procedure.
| Short Descr | MASTECTOMY FOR GYNECOMASTIA | Medium Descr | MASTECTOMY FOR GYNECOMASTIA | Long Descr | Mastectomy for gynecomastia | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1A - Major procedure - breast | MUE | 1 | CCS Clinical Classification | 167 - Mastectomy |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2025-01-01 | Changed | Short and Medium Descriptions changed. |
| 2007-01-01 | Added | First appearance in code book in 2007. |
| 1983-12-31 | Deleted | Code deleted. |
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