Mastectomy for gynecomastia

CPT code 19300 covers surgical removal of excess breast tissue in males (gynecomastia surgery), a procedure that reduces enlarged male breasts to create a flatter, more masculine chest contour.

Showing rates for

National Average

Base Medicare rate

$564.12

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

5.31

PE RVU (NF)

10.9

MP RVU

1.23

Total RVU

17.44

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

NCCI bundling edits

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Billing tips

Document medical necessity extensively with photographs, hormone levels, underlying etiology, failed conservative treatment, and psychological impact assessments to differentiate from cosmetic procedures
Impact: Prevents denial of entire $564.12 claim; cosmetic denials are the most common reason for non-payment and are difficult to overturn on appeal
Bill bilateral procedures with modifier 50 when both breasts are treated during same session rather than two separate line items, unless payer-specific guidelines require RT/LT modifiers
Impact: Ensures proper reimbursement of $846.18 for bilateral procedures versus risk of second side being denied or paid at reduced rate
Verify whether procedure will be performed in facility or non-facility setting before quoting patient responsibility, as the $136.50 difference affects both Medicare payment and coinsurance calculations
Impact: Non-facility setting yields $564.12 vs facility $427.62; affects practice revenue and patient out-of-pocket by 32%
Ensure diagnosis codes clearly indicate pathologic gynecomastia (N62) and underlying cause when known (E29.1 for testicular hypofunction, E28.1 for excess estrogen) rather than codes suggesting cosmetic concerns
Impact: Proper ICD-10 coding supports medical necessity determination; prevents automatic cosmetic denials that occur in approximately 30-40% of claims with improper diagnosis coding
Do not unbundle liposuction codes (15876-15879) when performed as part of the gynecomastia mastectomy; tissue removal including fat is included in 19300
Impact: Prevents denial of add-on codes typically worth $200-400 and avoids fraud/abuse flags that can trigger comprehensive audits

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Frequently asked questions

What is the Medicare reimbursement rate for CPT code 19300 in 2025?

The 2025 Medicare national average payment for CPT 19300 is $564.12 in non-facility settings and $427.62 in facility settings. These rates are based on total RVUs of 17.44 multiplied by the 2025 conversion factor of 32.3465. Actual payment may vary by geographic locality based on GPCI adjustments.

Is gynecomastia surgery covered by Medicare and commercial insurance?

Coverage depends on medical necessity documentation. Medicare and most commercial payers cover CPT 19300 when gynecomastia is pathologic (hormonal imbalance, medication side effect, underlying disease) and causes physical symptoms or significant psychological distress. Purely cosmetic gynecomastia correction is not covered. Prior authorization and extensive documentation including hormone studies, photographs, and psychological assessment are typically required.

How do you bill for bilateral gynecomastia surgery?

Bill CPT 19300 with modifier 50 for bilateral procedures performed during the same operative session. Medicare reimburses at 150% of the unilateral rate ($846.18 non-facility). Some commercial payers require two line items with RT and LT modifiers instead of modifier 50, so verify payer-specific bilateral surgery policies before submitting claims.

Can you bill liposuction separately with CPT 19300?

No, liposuction performed as part of the gynecomastia mastectomy is included in CPT 19300 and should not be billed separately using codes 15876-15879. Unbundling these services will result in denial and potential fraud investigation. The mastectomy code encompasses all tissue removal including glandular tissue and fat removal necessary to complete the gynecomastia correction.

What diagnosis codes support medical necessity for CPT 19300?

Primary diagnosis code N62 (hypertrophy of breast/gynecomastia) should be reported. Add secondary codes for underlying causes when applicable: E29.1 (testicular hypofunction), E28.1 (excess estrogen), E03.9 (hypothyroidism), E66.9 (obesity as contributing factor), or specific medication-induced codes. Avoid cosmetic-suggesting codes or symptoms-only codes that do not establish pathologic breast enlargement.

What is the work RVU for CPT 19300?

CPT 19300 has a work RVU of 5.31 for 2025. The total RVU is 17.44, consisting of 5.31 work RVU, 10.9 practice expense RVU (non-facility), 6.68 practice expense RVU (facility), and 1.23 malpractice RVU. These values reflect moderate surgical complexity and typically 60-90 minutes of intraoperative physician time.

Do you need prior authorization for CPT code 19300?

Prior authorization requirements vary by payer. Most Medicare Advantage plans and commercial insurers require prior authorization for CPT 19300 due to medical necessity concerns. Traditional Medicare does not require prior authorization but may subject claims to post-payment review. Always verify authorization requirements with the specific payer before scheduling surgery to avoid denial of the entire $564.12+ claim.