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Radical mastectomy, as defined by CPT® Code 19305, is a surgical procedure that involves the comprehensive removal of the entire breast, including the nipple and areola, along with the excision of the pectoralis major and minor muscles and the axillary lymph nodes. This procedure is typically indicated for patients diagnosed with breast cancer, where extensive tissue removal is necessary to ensure complete excision of malignant cells. The surgical approach often involves making an elliptical incision that encompasses the breast and extends into the axilla, an area known as the tail of Spence. During the operation, the surgeon removes the breast tissue, skin, areola, and nipple in a single unit, referred to as en bloc, along with the underlying pectoral muscles. Additionally, the axillary lymph nodes are meticulously dissected from the underlying axillary vein, as well as the adjacent nerves and muscles, to facilitate their removal. In certain cases, a more extensive procedure known as an Urban-type radical mastectomy may be performed, which includes the excision of internal mammary lymph nodes along with the previously mentioned structures. This procedure is critical in managing advanced breast cancer and may involve further dissection of surrounding tissues, including portions of the rectus fascia, latissimus dorsi muscle, and clavicle. The surgical site is then closed, and if there is insufficient skin for closure, a myocutaneous graft may be utilized, or a breast reconstruction procedure may be performed prior to closure. This comprehensive approach aims to achieve optimal oncological outcomes while addressing the physical changes resulting from the surgery.
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The radical mastectomy procedure, coded as CPT® 19305, is indicated for patients with specific conditions that necessitate extensive surgical intervention. The following are the primary indications for performing this procedure:
The radical mastectomy procedure involves several critical steps, each designed to ensure the thorough removal of cancerous tissues and associated structures. The following outlines the procedural steps involved:
Post-procedure care following a radical mastectomy is crucial for patient recovery and includes monitoring for complications, managing pain, and ensuring proper wound healing. Patients are typically advised to rest and limit physical activity for a specified period to promote healing. Drainage tubes, if placed, are monitored and managed to prevent fluid accumulation. Follow-up appointments are essential to assess the surgical site, remove any sutures, and discuss further treatment options, such as chemotherapy or radiation therapy, if indicated. Patients may also receive guidance on physical therapy to aid in recovery and regain mobility in the affected area.
| Short Descr | MAST RADICAL | Medium Descr | MAST RAD W/PECTORAL MUSCLES AXILLARY LYMPH NODES | Long Descr | Mastectomy, radical, including pectoral muscles, axillary lymph nodes | 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) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1A - Major procedure - breast | MUE | 1 | CCS Clinical Classification | 167 - Mastectomy |
| LT | Left side (used to identify procedures performed on the left side of the body) | 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). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 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. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | RT | Right side (used to identify procedures performed on the right side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2011-01-01 | Changed | Short description changed. |
| 2007-01-01 | Added | First appearance in code book in 2007. |
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