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Breast Cancer: Coding Prevention and Treatment

Breast Cancer: Coding Prevention and Treatment

Make a difference by developing an awareness of the anatomy, procedures, and payer policies.

In October, we raise awareness for breast cancer — the second most common cancer in women in the United States, according to the Centers for Disease Control and Prevention (CDC). Every year in the United States, there are about 264,000 new cases in women and 2,400 in men. The mortality rate is higher for women at 42,000 compared to 500 for men. Medical coders have a distinct opportunity to help patients by ensuring their diagnoses and treatments are billed correctly.

Identify Breast Anatomy

When reporting the diagnosis and treatments for a breast cancer patient, it’s important to understand the breast anatomy and the tissue types:

  • Lobules are glands that produce milk.
  • Ducts carry milk to the nipple.
  • Connective tissue, both fibrous and fatty, surrounds the lobules and ducts, holding them together.

Breast cancer can spread to other surrounding tissues, into the lymph nodes, and then travel elsewhere in the body. Early detection is essential for early treatment to prevent cancer from spreading (metastasis) and increase the chances of survival.

Take Preventive Measures

When a patient reaches a certain age, insurance carriers will cover preventive exams such as mammograms, and upon diagnosis, an ultrasound may be needed for follow-up.

CPT®, HCPCS Level II coding for mammography:

77067, G0279 – Screening mammography – This service is performed on asymptomatic patients as a preventive measure once they reach a certain age or have a family history indicating its need. Coverage for these services for Medicare and many commercial payers is indicated as once in a lifetime for women aged 35-39, once every 12 months for women age 40 or older, or more than once a year if medically necessary.

77065-77066 – Diagnostic mammography – This service is covered by Medicare and many third-party insurance payers if there are signs and symptoms of breast disease, a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease with a physician’s interpretation of the results.

These tests have professional and technical components, so append modifier 26 Professional component when billing the physician’s interpretation only or TC Technical component when billing the test only. Do not use either modifier if the provider performed both components.

Additionally, a physician may decide it is medically necessary to perform a diagnostic breast ultrasound. Coding depends on whether all or some structures are analyzed:

76641   Ultrasound, breast, unilateral, real-time with image documentation, including axilla when performed; complete

76642   Ultrasound, breast, unilateral, real-time with image documentation, including axilla when performed; limited

In a complete ultrasound, the physician examines all four quadrants of the breast — upper outer (UO), upper inner (UI), lower outer (LO), and lower inner (LI) — and the retroareolar region (the region within 2 cm from the nipple). In a limited exam, the physician examines one to three areas.

In both codes, the axillary region (low, mid, apical) is viewed or is intended to be viewed. The anatomy of the axillary region is often confused for an extremity or musculoskeletal structure due to its proximity to the upper extremity. The physician may analyze the axilla, but the main portion of the test is looking at the breast tissue; looking at the axillary region may indicate lymph node involvement.

Breast Cancer Diagnosis and Staging

After a diagnosis of breast cancer or for those who are at high risk of breast cancer, magnetic resonance imaging (MRI) may be indicated for the extent of the disease. MRI detection is more sensitive, especially for women with dense breast tissue. It can even detect invasive breast cancer a lot sooner than in women who only receive a mammogram. The codes that utilize MRI guidance or computer-aided detection (CAD) are:

77046    Magnetic resonance imaging, breast, without contrast material; unilateral

77047              bilateral

77048    Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization, and pharmacokinetic analysis) when performed; unilateral

77049              bilateral

Once a diagnosis is confirmed and treatment of a surgical nature is recommended, the physician will use what they have learned through imaging to order the best, most effective treatment for the patient. Working closely with the surgeon to accurately report these codes is vital. Michael J. Cross, MD, FACS, (Certified by The American Board of Surgery), a breast surgical oncologist in Northwest Arkansas, states:

Accuracy in coding and the intention of the code is at the top of the list. This requires a collaborative effort between the doctor and the coder. A surgeon is familiar with the anatomy of the breast including the axilla. Most of the time it will be a surgeon who also will want to take their ultrasound to the OR and use it to place wires, to evaluate the location of cancer, or use it for axillary evaluation. Ultrasound of the surgical specimen can be used to determine the margins and to remove a specific lymph node in surgery as well as used in the office for diagnostic imaging and confirmation of the location of cancer that has been diagnosed. A coder can help the surgeon include essential information that needs to be present that will lead to a clean code, clean claim, and hopefully a clean reimbursement.

Surgical Treatment Challenges

After a patient has been diagnosed with breast cancer, the next process is weighing the surgical and medical options for treating the disease. The physician will discuss with the patient the best treatment options depending on the type of breast cancer, the stage, the size, sensitivity to hormones, and if it has metastasized.

Treatment options are considered based on the stage and may consist of surgical options such as excision of a breast lesion (19120, 19125), lumpectomy (19301-19302), and mastectomy (19303, 19305.

A 19125 is performed to remove abnormal breast tissue or lumps such as cysts or tumors. In a 19301, the surgeon removes a single lump or portion of the breast tissue; whereas in a 19302, a single lump or portion of the breast tissue is removed and lymph nodes between the pectoralis major and minor muscles and in the axilla are removed through a separate incision. A 19303 is a simple, complete surgery to remove the entire breast or both breasts (double mastectomy); and a 19305 is a radical mastectomy — removal of breasts, underarm lymph nodes, and chest muscles.


Lumpectomy is also termed partial mastectomy and is the complete surgical removal of a primary tumor, but not a complete removal of the breast. Types of lumpectomy procedures are excisional biopsy, wide local excision, and re-excision lumpectomy. The key to reporting a lumpectomy procedure is understanding how much tissue is being excised or removed.

Codes 19120 and 19301 can often be confused. The key to choosing the correct code is the intent of the procedure, the tissue involved, and the diagnosis. Cancer is not always a reason to go right to a 19301. Consider what is being excised; for example, with 19301, the surgeon will take a margin or rim of healthy tissue. The intent, of course, is to capture the mass within the breast tissue at the area of concern, but removal of additional structures may be required. If the intent is to remove the lump and the lymph nodes between the pectoralis major and the pectoralis minor muscles, in addition to the nodes in the axilla, this would be a complete axillary lymph excision, reported with 19302.

In many cases, the surgeon may not take the full axillary chain and just remove some of the axillary lymph nodes. Instead of utilizing a modifier, the appropriate step is to utilize additional CPT® codes to describe this work; 38500 and 38525 describe the extra work of excising the lymph nodes during a partial mastectomy without removing the full chain.

In cases where cancer is advanced, radiation therapy after a partial mastectomy may be utilized. Codes are assigned as add-on services to 19301 and 19302 for the placement of radiotherapy after loading expandable catheters, which includes imaging guidance either on the day of the procedure (19297) or on a separate day (19296). The surgeon will work with the radiation oncologist as the radiation is delivered at a frequency of twice daily for five to seven days, depending on the type of cancer.


Mastectomy (simple or complete) involves the complete removal of all breast tissue. Types of mastectomy procedures are total mastectomy, double mastectomy, nipple-sparing mastectomy, and radical mastectomy. A complete mastectomy involves the entire breast and not just a lump and surrounding tissue. The nipple can be spared and preserved to use later in reconstruction. A radical mastectomy involves taking margins for removal of surrounding muscle tissue and nearby lymph nodes. What the surgeon takes will differ and necessitate use of various code options, so attention to detail and a clear understanding of anatomy are key when coding these procedures.

Surgical Reconstruction of the Breast

After a patient receives surgical treatment, breast reconstruction may be needed to restore shape to the post-surgical breast. Reconstruction can be done at the time of a mastectomy or afterward. A breast surgeon can perform a skin-sparing mastectomy to save as much skin as possible for the reconstruction phase.

Reconstruction may be done in two stages: First a tissue expander is placed that will be filled with saline at various visits post-mastectomy. Then, with hopefully enough healing taking place, the second stage is to remove the expander and insert the implant. There are many ways to reconstruct a breast using flaps and grafts from various anatomical sites on the body such as the abdomen, back, thigh, or buttocks.

The challenge with these procedures from a billing standpoint is that many insurances may view them as cosmetic and deny coverage. Clear documentation showing medical necessity is crucial not only for prior authorization but also to stand up to an appeal if a denial takes place.

To obtain proper reimbursement, review the Women’s Health and Cancer Rights Act of 1998 (WHCRA) for breast cancer patients. Under this law, coverage must be provided for:

  • All stages of reconstruction of the breast on which the mastectomy has been performed;
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
  • Prostheses and treatment of physical complications of all stages of the mastectomy, including lymphedema.

This law applies to group health plans (provided by an employer or union) and individual health insurance policies (not based on employment).

Coding requires you to first determine what is being ordered, the reason, and what additional procedures are being performed at that time that may be bundled or included in the service. Common reconstructive procedures and ancillary services that are separately reportable include the following:

19361   Breast reconstruction; with latissimus dorsi flap

A surgeon will utilize tissue expanders, implants, skin or muscle flaps, and other reconstructive devices to reconstruct a breast after mastectomy. Additional procedures may be needed to achieve the desired size or shape. The reconstruction will utilize a latissimus dorsi flap. This involves a transfer of skin and muscle from the patient’s back to their affected breast to correct the defect created by the mastectomy, typically a radical procedure when the cancer was the reason for the mastectomy. It’s called a latissimus dorsi flap because the muscle and skin are taken from nearby structures. The flap under the armpit is rotated so that it can cover the mastectomy site. Guidelines allow for separate reporting of a breast implant or tissue expander with the reconstruction, as necessary.

This is currently an inpatient-only code per the inpatient code list provided by the Centers for Medicare & Medicaid Services (CMS). Similar services include CPT® 19364, 19367, 19368, and 19369.

19380    Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction)

This code is utilized to reconstruct a breast or nipple after a mastectomy. Included in this code are tissue expanders, implants, skin or muscle flaps, and other reconstructive devices, when performed. There may be ancillary procedures performed and billed to allow for a desired size or shape. It’s important that the medical necessity criteria are met for this procedure. Payers may consider this procedure cosmetic, and they also may have a yearly limit on how many times this procedure can be performed.

19318    Breast reduction

This is also referred to as a reduction mammoplasty. While this can be done for cosmetic purposes, there are medically necessary reasons to perform the procedure and various policies that need to be consulted for coverage criteria. Make sure that documentation includes all the required information to support medical necessity. Physicians will typically document breast hypertrophy or an increase in the volume and weight of breast tissue as it relates to the general body habitus. This condition can affect other body systems such as musculoskeletal, respiratory, and integumentary. When one-sided hypertrophy exists, it may result in symptoms on the contralateral side where the mastectomy took place. The amount of tissue that must be removed to relieve symptoms will vary and depend upon such things as height, weight, and breast size.

The Schnur Sliding Scale method is generally used to evaluate the need for a reduction. If the patient’s combined body surface area and weight of breast tissue falls above the 22nd percentile, then surgery is considered medically necessary. To receive approval from the insurance provider, you will usually need to provide pre-op photos to confirm this evaluation. Documentation is key.

19328    Removal of intact breast implant

Last year, breast reconstruction CPT® codes underwent a major revision, 19328 included. The reason to perform a breast implant removal for medical necessity is due to infection or an abscess. The physician may state the procedure will be for the “removal of a breast implant with washout.” This code will include the drainage of any associated abscess cavity or infection. As with other areas of CPT®, debridement of nonviable tissue associated with the breast implant or soft tissues is not reported separately. In other revised codes for 2021, the removal of the implant is an integral part of the procedure and not separately billable, such as in 19370 or 19371, where part of the intracapsular contents is removed in a capsulectomy. (CPT® Assistant April 2021, Vol. 31 Issue 4)

+15777 Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk)

This add-on code corrects a soft tissue defect of the trunk or breast. It’s important to check individual payer coverage policies for approved products for this type of graft. Just because prior authorization for 15777 has been received or is not required, you are not guaranteed payment; some commercial carriers have coverage criteria and require the use of an FDA-approved product and will deny payment for products deemed experimental or investigational.

In the Medicare Physician Fee Schedule (MPFS), 15777 has a medically unlikely edit (MUE) of 1, but an MUE adjudication indicator of 3. The MPFS identifies different procedures with indicators to allow for additional units on that claim line. If an indicator of 3 is used, per CMS, “appealed additional units are considered if there is adequate documentation of medical necessity to support reported units.” Do not let these slip by; claims can be appealed and paid.

Remember the Goal

With a good understanding of the guidelines, disease process, and regulatory guidance from Medicare and other payers, you can be successful in helping your patients obtain these much-needed services. The goal is always early detection, but when you understand the correct documentation and communication needed between these different service lines, your patients can get the care they need to improve their quality of life.


Jennifer McNamara
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About Has 4 Posts

Jennifer McNamara, CPC, CCS, CPMA, CRC, CPC-I, CGSC, COPC, is the director of education and coding for Oncospark. She has 20+ years of proven healthcare revenue cycle experience and effective instruction through Ozark Institute for 1000+ students. McNamara has worked in many specialized areas of coding including auditing, consulting, RCM services, credentialing, and compliance. She is the host of the weekly podcast “Life as a Coder” every Wednesday discussing health information management and tips work-life balance.

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