Mastotomy expl drg absc dp

CPT 19020 covers a surgical procedure where a surgeon makes an incision into the breast tissue to drain a deep abscess (a collection of pus from an infection). This is more extensive than simple needle drainage and requires opening the breast tissue to reach and clean out the infected area.

Showing rates for

National Average

Base Medicare rate

$447.35

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

3.83

PE RVU (NF)

9.11

MP RVU

0.89

Total RVU

13.83

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Document depth and exploration thoroughly in operative report to distinguish from simple I&D code 10061, which pays significantly less
Impact: Proper documentation supports $447.35 vs approximately $180 for simple I&D - difference of $267.35 per case
Bill in non-facility setting when performed in office-based OR or ASC to capture full non-facility rate
Impact: Non-facility rate of $447.35 versus facility rate of $308.91 - additional $138.44 in reimbursement
Always append RT or LT modifier to prevent automatic denial; many Medicare MACs and commercial payers auto-reject without laterality
Impact: Prevents initial denial and 30-60 day delay in payment while appealing or resubmitting
Consider modifier 22 for extensive abscesses requiring significant additional work, but document exact additional time, complexity, and findings
Impact: Can increase reimbursement by 20-30% ($89-134 additional) when properly documented with comparative metrics
Verify medical necessity documentation includes failed conservative treatment (antibiotics, needle aspiration) before surgical drainage
Impact: Medical necessity is frequent audit target; proper documentation prevents recoupment of entire $447.35 payment
Link appropriate ICD-10 codes for abscess location and lactation status; N61.1 (abscess of breast) requires additional specificity
Impact: Specific diagnosis coding (lactational vs non-lactational) supports medical necessity and prevents denials

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 19020 in 2025?

The 2025 Medicare national average reimbursement for CPT 19020 is $447.35 in the non-facility setting and $308.91 in the facility setting. Actual reimbursement may vary based on geographic locality adjustments (GPCI).

What is the difference between CPT 19020 and simple I&D codes 10060/10061?

CPT 19020 specifically involves mastotomy with exploration to drain a deep breast abscess, requiring incision through breast parenchyma and surgical exploration of the abscess cavity. Codes 10060/10061 are for simple or complicated skin abscess drainage that does not involve deep breast tissue exploration. The depth, anatomic location within breast tissue, and extent of surgical exploration distinguish these codes.

How many RVUs is CPT code 19020 worth?

CPT 19020 has a total of 13.83 RVUs for 2025, consisting of 3.83 work RVUs, 9.11 non-facility practice expense RVUs (4.83 facility PE RVUs), and 0.89 malpractice RVUs.

Do I need a modifier when billing CPT 19020?

Yes, laterality modifiers RT (right) or LT (left) are typically required by Medicare and most commercial payers to indicate which breast was treated. Additional modifiers like 50 (bilateral), 22 (increased complexity), or 78/79 (return to OR) may be appropriate depending on the clinical circumstances.

Can CPT 19020 be billed with an E/M code on the same day?

Yes, but only if the E/M service represents a separately identifiable evaluation that led to the decision for surgery. You must append modifier 25 to the E/M code and document a distinct evaluation beyond the usual pre-operative assessment. Many payers scrutinize same-day E/M billing with surgical procedures.

What diagnosis codes support medical necessity for CPT 19020?

Primary diagnosis codes include N61.1 (abscess of the breast and nipple), with additional specificity for lactational status: O91.13 (abscess of breast associated with lactation) or N61.1 for non-puerperal abscess. Supporting documentation should show the abscess is deep within breast tissue and requires surgical drainage rather than simple percutaneous approach.

Is CPT 19020 covered bilaterally, and how should it be billed?

Bilateral mastotomy with abscess drainage is rare but can be billed using modifier 50 when both breasts require the procedure during the same operative session. This typically reimburses at 150% of the unilateral rate. Alternatively, some payers prefer two line items with RT and LT modifiers. Verify payer-specific bilateral surgery policies before billing.