Mast rad urban type

CPT code 19306 covers a radical mastectomy with removal of the breast, underlying chest muscles, and lymph nodes, sometimes called an Urban-type or extended radical mastectomy. This is one of the most extensive forms of breast cancer surgery performed when cancer has spread to the chest wall muscles.

Showing rates for

National Average

Base Medicare rate

$1,196.82

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

18.13

PE RVU (NF)

14.26

MP RVU

4.61

Total RVU

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

NCCI bundling edits

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Billing tips

Ensure operative report explicitly documents removal of both pectoralis major AND minor muscles to justify 19306 versus the less extensive 19305
Impact: Coding 19306 instead of 19305 yields $166.94 higher reimbursement; downcoding due to incomplete documentation costs this differential
Document extent of axillary lymph node dissection including levels dissected (I, II, III) and number of nodes removed to support medical necessity
Impact: Prevents medical necessity denials and supports the 18.13 work RVU; inadequate documentation may result in complete claim denial worth $1196.82
Bill in the facility setting only as this is an inpatient hospital procedure; both facility and non-facility rates are identical at $1196.82 for 2025
Impact: No rate differential exists, but billing with incorrect place of service may cause processing delays or denials
When chest wall reconstruction is performed immediately, bill separately with appropriate plastic surgery codes (15734, 19357) as these are not bundled with 19306
Impact: Additional $800-$2000 in legitimate reimbursement for immediate reconstruction; failing to bill these separately leaves money on the table
Use modifier 22 only when operative time exceeds 4-5 hours due to tumor extent, previous radiation, or complex chest wall involvement; submit operative report with claim
Impact: Successful modifier 22 claims yield 20-50% additional payment ($239-$598), but approval rate is only 30-40% without compelling documentation
Verify that pathology report confirms muscle tissue in specimen to substantiate the radical nature of the procedure and defend against post-payment audits

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Frequently asked questions

What is the difference between CPT 19306 and 19305 for mastectomy coding?

CPT 19306 requires removal of both the pectoralis major AND pectoralis minor muscles along with the breast and axillary lymph nodes (radical mastectomy, Urban type), while 19305 removes only the pectoralis major muscle. The distinction adds $166.94 to Medicare reimbursement but requires explicit documentation of both muscles being resected. If the operative report only documents pectoralis major removal, 19305 is the correct code.

How much does Medicare pay for CPT code 19306 in 2025?

Medicare pays $1,196.82 for CPT 19306 in 2025 based on the national average rate. Both the facility and non-facility rates are identical at $1,196.82. The code carries 18.13 work RVUs and 37 total RVUs, reflecting the extensive nature of this radical surgical procedure.

Is CPT 19306 still used or has it been replaced by other mastectomy codes?

CPT 19306 is still active but rarely used in modern breast cancer surgery. Modified radical mastectomy (19307) has largely replaced this procedure because current oncologic practice rarely requires removal of the pectoral muscles. 19306 is reserved for cases of direct muscle invasion by tumor or specific recurrent disease scenarios where muscle resection is oncologically necessary.

Can I bill axillary lymph node dissection separately with CPT 19306?

No, axillary lymph node dissection is included in CPT 19306 and should not be billed separately using codes like 38740 or 38745. The descriptor and RVU value for 19306 already account for the axillary dissection component. Billing both will result in bundling denials and potential audit flags for unbundling.

What modifiers are required when billing CPT 19306?

Laterality modifiers LT (left) or RT (right) are required for CPT 19306 to specify which breast was operated on. Modifier 50 can be used for bilateral procedures (extremely rare). Modifier 22 may be appropriate for unusually extensive procedures requiring significantly more work than typical, but requires detailed documentation and often manual review for payment.

What documentation is needed to prevent denials for CPT 19306?

Essential documentation includes: explicit mention of both pectoralis major AND minor muscle removal in the operative report, preoperative imaging showing muscle invasion, description of axillary lymph node dissection with levels, clear laterality, and pathology report confirming muscle tissue in the specimen. Medical necessity for the radical approach versus less extensive mastectomy must be clearly justified.

Can immediate breast reconstruction be billed with CPT 19306?

Yes, immediate breast reconstruction codes (such as 19357 for tissue expander or 19364 for flap reconstruction) can and should be billed separately with CPT 19306 as these are not bundled procedures. This represents legitimate additional reimbursement of $800-$2,000+ depending on the reconstruction method. Ensure the plastic surgeon or performing surgeon bills the reconstruction code with appropriate documentation.