Coding for nipple-sparing and skin-sparing mastectomies

In December 2007, an American Medical Association (AMA) CPT [Current Procedure Terminology] Assistant Newsletter article was published indicating that a skin-sparing mastectomy should be reported with CPT* code 19304, Mastectomy, subcutaneous.1 The CPT article incorrectly indicated that nipple-sparing does not change the subcutaneous dissection performed. The correct code to report skin-sparing mastectomy is 19303, Mastectomy, simple, complete (total mastectomy). It is worth noting that the American College of Surgeons (ACS) did not provide the coding interpretation published in this 2007 CPT Assistant Newsletter article regarding the code to report for skin-sparing mastectomy. Moreover, the American Society of Breast Surgeons (ASBrS) was not a member of the AMA CPT Advisory Committee in 2007 and, therefore, could not contribute to CPT Assistant Newsletter articles.

In 2015 the ACS submitted a clarification to the 2007 CPT Assistant Newsletter article, which was published in the March 2015 issue.2 However, the earlier 2007 article was not deleted, retracted, or marked in any way to indicate that the information featured in the article was incorrect. Because the 2007 and 2015 articles are both maintained in the CPT Assistant Newsletter archives, confusion persists regarding correct coding for skin-sparing and nipple-sparing mastectomies. Some coding consultants continue to direct surgeons and coders to incorrectly report 19304 for procedures that should be reported with 19303.

Distinctions between complete mastectomy and subcutaneous mastectomy

A skin-sparing or nipple-sparing mastectomy for diagnosed carcinoma, or for patients who are at high risk for carcinoma, is reported with code 19303 regardless of the amount of skin removed or whether the nipple is preserved. These oncologic procedures require removal of the entire breast tissue in one or both breasts plus additional surgical work, such as attention to surgical margins, specimen orientation, and cold ischemic time.

In contrast, subcutaneous mastectomy is typically used to treat patients with severe symptomatic fibrocystic change or patients who are undergoing breast cosmetic procedures in which significant tissue removal is necessary to achieve symmetry. The incision is generally conservative and cosmetic, and some breast tissue is left behind. Thus, it is not a “complete” mastectomy.

What to include in the operative report

To clarify reporting, the operative report should include the wording “nipple-sparing complete mastectomy” or “skin-sparing complete mastectomy,” as well as the appropriate International Classification of Disease, 10th Revision, Clinical Modification code for diagnosed malignancy (such as C50.XXX or D05.XX) or for increased future breast cancer risk (such as Z15.01). Use of the specific term “complete mastectomy” will help direct the coders to correctly report 19303, Mastectomy, simple, complete. This change is consistent with Version 1.2017 of the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Breast Cancer Risk Reduction: “Nipple-sparing mastectomy is a total mastectomy with preservation of the nipple/areola and breast skin. Efforts should be made to minimize the amount of residual breast tissue.”3

The distinction between a simple, complete mastectomy and subcutaneous mastectomy is similar to the biopsy/lumpectomy distinction, which also led to coding confusion a decade ago due to incorrect coding advice. Today, it is well understood that these procedures are not reported based on the volume of tissue removed, but rather on the intent to achieve negative margins. For example, excision of a 4 cm fibroadenoma in a 19-year-old patient is reported with code 19120, Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions (breast biopsy). In contrast, excision of an 8 mm carcinoma via a 2.5 cm surgical specimen is reported with code 19301, Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy).

To summarize, report code 19303 for a skin-sparing or nipple-sparing mastectomy for diagnosed carcinoma or for patients who are at high risk for carcinoma, regardless of the amount of skin removed or whether the nipple is preserved.

The “Coding and practice management corner” column in the September 2014 Bulletin provides additional guidance on breast surgery coding.4

Note

Accurate coding is the responsibility of the provider. This summary is intended only to serve as a resource to assist in the billing process.


*All specific references to CPT codes and descriptions are ©2016 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.

References

  1. American Medical Association. Surgery: Integumentary system. CPT Assistant Newsletter. 2007;17(12):7.
  2. American Medical Association. Coding brief: Coding for breast surgery. CPT Assistant Newsletter. 2015;25(3):5,11.
  3. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology for Breast Cancer Risk Reduction, Version 1.2017. Password protected. Available at: nccn.org/professionals/physician_gls/pdf/breast_risk.pdf. Accessed January 24, 2017.
  4. Barney L, Savarise MT, Whitacre E. Coding and practice management corner: Frequently asked questions about coding for breast surgery. Bull Am Coll Surg. 2014; 99(9):52-54. Available at: bulletin.facs.org/2014/09/frequently-asked-questions-about-coding-for-breast-surgery/. Accessed February 14, 2017.

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