Mast simple complete

CPT code 19303 covers a simple complete mastectomy, which is the surgical removal of an entire breast without removing lymph nodes or chest wall muscles. This is typically performed for cancer treatment or high-risk prevention.

Showing rates for

National Average

Base Medicare rate

$940.31

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

PE RVU (NF)

10.33

MP RVU

3.74

Total RVU

29.07

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

NCCI bundling edits

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Billing tips

Always append laterality modifiers (RT/LT) even for unilateral procedures to prevent automatic denials
Impact: Prevents 15-20% of claims from being denied or suspended for additional information; saves average 14-day payment delay
For bilateral procedures, verify payer policy on modifier 50 versus RT/LT on separate lines before submission
Impact: Incorrect bilateral billing method causes payment delays and potential underpayment of $200-400 per case
Do not unbundle sentinel lymph node biopsy (38900) or axillary node sampling; these require separate medical necessity and are not included in 19303
Impact: Proper separate billing of 38900 adds $376.82 Medicare reimbursement when medically necessary and documented
Document medical necessity clearly for prophylactic mastectomy including genetic testing results, family history, and risk assessment
Impact: Prevents denials worth $940.31 per breast; prophylactic procedures have 25-30% higher initial denial rate without genetic documentation
Use modifier 22 with detailed operative report when procedure time exceeds 2.5 hours or significant scar tissue from radiation documented
Impact: Successful modifier 22 appeals yield average additional payment of $250-400 (25-45% increase) per case
Verify coverage for tissue expander placement (19357) as separate procedure when performed; not included in 19303 base code
Impact: Tissue expander placement adds $514.52 Medicare reimbursement when properly documented as separate distinct procedure

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Frequently asked questions

What is the CPT code 19303 Medicare reimbursement rate for 2025?

The 2025 Medicare national average reimbursement rate for CPT 19303 is $940.31 for both facility and non-facility settings. This rate is based on 29.07 total RVUs multiplied by the 2025 conversion factor of $32.3465.

What is the difference between CPT 19303 and 19304?

CPT 19303 is a simple complete mastectomy removing only breast tissue without lymph nodes, while 19304 is a subcutaneous mastectomy where skin and nipple are preserved. Code 19303 involves complete skin and nipple removal, whereas 19304 preserves the skin envelope for reconstruction.

Can CPT 19303 be billed bilaterally with modifier 50?

Yes, CPT 19303 can be billed bilaterally using modifier 50, but you should verify payer-specific policies. Medicare typically reimburses bilateral procedures at 150% of the unilateral rate. Some payers prefer two line items with RT and LT modifiers instead of modifier 50.

Is lymph node removal included in CPT 19303?

No, CPT 19303 specifically excludes lymph node removal. This is a simple complete mastectomy without axillary lymph node dissection. Sentinel lymph node biopsy (38900) or axillary lymphadenectomy can be billed separately when medically necessary and documented.

What documentation is required for prophylactic mastectomy billing with 19303?

Prophylactic mastectomy requires genetic testing results (BRCA1/BRCA2 or other mutations), documented high-risk assessment, detailed family history, and medical necessity statement. Without genetic or strong clinical risk documentation, prophylactic mastectomy claims have significantly higher denial rates.

Can breast reconstruction be billed on the same day as CPT 19303?

Immediate breast reconstruction can be billed separately from CPT 19303, but requires appropriate documentation showing distinct procedures. Tissue expander placement (19357) or implant insertion (19340) are separately billable. Always check for bundling edits and use modifier 59 when appropriate to indicate distinct procedural services.

How many RVUs is CPT code 19303 worth in 2025?

CPT 19303 has 29.07 total RVUs in 2025, consisting of 15.00 work RVUs, 10.33 practice expense RVUs, and 3.74 malpractice RVUs. Both facility and non-facility settings have identical RVU values for this code.