Mast mod rad
CPT code 19307 covers a modified radical mastectomy, a surgical procedure to remove breast tissue, the nipple, and underarm lymph nodes, typically performed to treat breast cancer. This is less extensive than a radical mastectomy but more extensive than a simple mastectomy.
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
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
NCCI bundling edits
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Billing tips
Always append RT or LT modifier to indicate laterality; claims without laterality modifiers are automatically denied
Impact: Prevents 100% claim denial and 2-4 week payment delay
Do not separately bill sentinel lymph node biopsy (38500) or axillary node dissection when nodes are removed as part of standard MRM; these are bundled into 19307
Impact: Prevents $300-800 in unbundling denials and potential fraud investigation
For bilateral procedures performed same day, bill with modifier 50 rather than two line items with RT/LT; payer-specific rules vary
Impact: Medicare pays 150% for bilateral vs. potential underpayment; maximizes reimbursement by approximately $577
When immediate tissue expander or implant reconstruction follows MRM, coordinate billing with plastic surgeon using modifier 62 if co-surgery approach
Impact: Proper modifier use ensures both surgeons receive appropriate payment without bundling edits
Document medical necessity including tumor size, location, multifocality, patient preference discussions, and why breast conservation was inappropriate
Impact: Reduces audit risk and supports medical necessity; lack of documentation causes 15-20% of payment recoupments
Submit pathology report with claim for initial submission when possible; confirm final pathology matches diagnosis codes used
Impact: Accelerates clean claim processing by 7-10 days and prevents diagnosis-related denials
Common denials
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