19303

Mastectomy, simple, complete; with axillary lymphadenectomy

This procedure involves the surgical removal of the entire breast tissue, including the nipple-areola complex, skin, and underlying pectoral fascia. It is categorized as a simple, complete mastectomy. Crucially, CPT code 19303 specifies that this simple mastectomy is performed with an axillary lymphadenectomy, meaning the lymph nodes within the axilla (armpit) are also removed. The extent of lymph node removal can vary (e.g., levels I, II, or sometimes III) based on clinical staging, surgeon's discretion, and pathological findings, but the inclusion of axillary lymph node dissection is the distinguishing factor for this code. This procedure is typically performed for invasive breast cancer where regional lymph node involvement is suspected or confirmed, or for high-risk cases warranting comprehensive surgical management.

Clinical Indications

  • Invasive breast cancer with evidence or high suspicion of axillary lymph node involvement based on imaging, biopsy, or sentinel lymph node status.
  • Locally advanced breast cancer requiring definitive surgical removal of both primary tumor and regional nodal disease, often following neoadjuvant therapy.
  • Recurrent breast cancer where mastectomy is indicated and prior axillary evaluation necessitates further dissection.
  • Extensive or multifocal ductal carcinoma in situ (DCIS) where breast-conserving surgery is not feasible and axillary staging via lymphadenectomy is deemed necessary.
  • Prophylactic mastectomy in high-risk patients (e.g., BRCA mutation carriers) with a personal history of breast cancer or other compelling reasons necessitating concomitant axillary lymphadenectomy.

Procedure Steps

  1. Patient is placed in a supine position with the ipsilateral arm abducted to expose the breast and axilla; general anesthesia is administered.
  2. An elliptical incision is made around the breast, typically encompassing the nipple-areola complex, to ensure adequate margins for complete breast tissue removal.
  3. Dissection of the breast tissue from the overlying skin flaps and the underlying pectoralis major fascia, ensuring complete removal of all mammary tissue.
  4. Careful hemostasis is achieved throughout the breast dissection.
  5. Extension of the dissection into the axilla to perform lymphadenectomy, meticulously dissecting lymph nodes from the axillary vein, nerves (e.g., long thoracic and thoracodorsal nerves), and muscle borders.
  6. Removal of the breast and axillary contents en bloc, with orientation of specimens for accurate pathological examination.
  7. Irrigation of the surgical site and placement of suction drains in both the breast flap and axillary spaces to prevent seroma formation.
  8. Layered closure of the skin flaps and incision.
  9. Application of a sterile dressing to the operative site.

Coding Guidelines

  • Code 19303 includes both the simple, complete mastectomy and the axillary lymphadenectomy. It is inappropriate to report separate codes for the lymphadenectomy when performed as part of this bundled procedure.
  • This code has a 90-day global surgical period, covering routine pre-operative, intra-operative, and post-operative care for 90 days following the surgery.
  • For bilateral procedures, append modifier 50 (Bilateral Procedure) to 19303 or report with modifiers RT and LT if required by the payer.
  • Thorough documentation must clearly describe the complete removal of breast tissue and the extent of axillary lymph node dissection (e.g., levels I, II, III).
  • If breast reconstruction is performed immediately following the mastectomy, it should be reported separately using appropriate CPT codes (e.g., 19361, 19357, 19340, 19342).
  • If only a sentinel lymph node biopsy is performed (and not a full axillary lymphadenectomy), CPT code 19307 (Mastectomy, simple, complete; with sentinel lymph node biopsy) should be reported instead of 19303. If a sentinel lymph node biopsy leads to positive nodes followed by a complete axillary dissection in the same operative session, 19303 typically encompasses the entire axillary procedure.
  • Skin-sparing or nipple-sparing mastectomies, when performed with axillary lymphadenectomy and meeting the criteria for complete breast tissue removal, may also be reported with 19303; however, specific payer policies should be consulted for unique scenarios.

Associated ICD-10 Codes