General Surgery Coding Alert

Question: Our surgeon performed an oncoplastic modified radical mastectomy with inverted T incision. Should I report this as 19316 along with the 19307?

Tennessee Subscriber

Answer: The correct code for this service is 19307 (Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle).

Surgeons commonly use the inverted T incision as part of a modified radical mastectomy. The mastectomy with this type of incision provides a breast conserving therapy. The inverted T incision is especially common for modified radical mastectomy when the tumor is situated in the central or inferior quadrant of the breast.

Although you are correct that you would code a cosmetic mastopexy -- which also often uses the inverted T incision -- as 19316 (Mastopexy), you should not additionally use this code. The surgeon performs a single procedure at the site, and you should code it as such.

-- Reader Questions and You Be the Coder were prepared with the assistance of Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program.