Total Mastectomy
19303
-
19302— Partial mastectomy with axillary lymphadenectomy -
19307— Modified radical mastectomy
Right/left breast carcinoma / DCIS / high-risk prophylactic mastectomy (BRCA1/2)
Same
Right/left total mastectomy [with sentinel lymph node biopsy]
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old female with [right/left] [invasive ductal/lobular/ductal in situ] carcinoma of the breast [measuring ___ cm on imaging] presenting for [therapeutic/prophylactic/nipple-sparing/skin-sparing] mastectomy. The risks, benefits, and alternatives were discussed with the patient, including reconstruction options, and informed consent was obtained. [Plastic surgery was present/available for reconstruction.]
The breast parenchyma was [normal/dense/with a palpable mass in the ___ quadrant]. [The sentinel lymph node biopsy demonstrated [negative / positive for metastasis] on frozen section.] [No satellite lesions, skin involvement, or chest wall fixation was noted.] [Additional findings or none].
The patient was brought to the operating room and placed supine with the ipsilateral arm abducted on an arm board. General endotracheal anesthesia was induced. A surgical timeout was performed confirming patient identity, procedure, operative site (right vs. left), allergies, and administration of prophylactic antibiotics.
The chest and axilla were prepped and draped in sterile fashion. [For sentinel lymph node biopsy: [5 mL of isosulfan blue dye / technetium-99m sulfur colloid was injected periareolar / peritumoral preoperatively] and the axilla was inspected for blue-staining nodes and/or hot nodes with a gamma probe. [___ sentinel lymph nodes were identified and excised; nodes were confirmed to have [___] counts on the gamma probe. The nodes were sent for frozen section — result: [negative/positive].]]
A transverse [or elliptical] skin incision was made encompassing the nipple-areola complex and any biopsy sites. [For skin-sparing: a periareolar incision was made preserving the skin envelope.] The incision was carried through the skin and subcutaneous tissue. Superior and inferior skin flaps were elevated with electrocautery in the plane between the subcutaneous fat and breast parenchyma, taking care to leave adequate skin flap thickness (approximately 5-8 mm of subcutaneous fat). Flaps were elevated superiorly to the clavicle, inferiorly to the inframammary fold, medially to the sternum, and laterally to the anterior border of the latissimus dorsi.
The breast was dissected from the pectoralis major fascia using electrocautery, sweeping the gland off the muscle from medial to lateral. The tail of Spence was dissected from the anterior axillary fat. The specimen was removed. The pectoral fascia was included with the specimen.
The wound was irrigated with warm saline. Hemostasis was confirmed. [A closed suction drain was placed in the mastectomy flap space.] [Plastic surgery performed immediate [tissue expander/implant/flap] reconstruction.] The wound was closed in two layers — [3-0 Vicryl] deep dermal sutures and [4-0 Monocryl] subcuticular closure. Sterile dressings were applied.
None
Right/left breast (total mastectomy specimen) [with sentinel lymph nodes] sent to pathology
Minimal (less than 50 mL)
One closed suction [Jackson-Pratt / Blake] drain in the mastectomy flap space
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: *** breast ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** total mastectomy ***
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old female with *** breast *** presenting for mastectomy. Reconstruction *** discussed. Informed consent obtained.
FINDINGS: Breast ***. Sentinel node ***. No skin involvement or chest wall fixation.
DESCRIPTION OF PROCEDURE:
Supine, arm abducted. General anesthesia. Surgical timeout per protocol — laterality confirmed.
*** Sentinel lymph node biopsy: *** nodes identified with blue dye/gamma probe; frozen section ***.
Elliptical incision encompassing NAC. Skin flaps elevated to clavicle, sternal border, IMF, and anterior latissimus. Breast dissected from pectoralis fascia medial to lateral; tail of Spence freed. Specimen removed with pectoral fascia.
Wound irrigated. JP drain placed. *** reconstruction. Deep dermis 3-0 Vicryl; skin 4-0 Monocryl.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Mastectomy specimen *** to pathology
COMPLICATIONS: None
DRAINS: JP drain
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Skin-Sparing Mastectomy
A skin-sparing mastectomy was performed through a periareolar incision with excision of the nipple-areola complex. The skin envelope was preserved for reconstruction. Skin flaps were elevated as described, maintaining the skin envelope. Immediate reconstruction with [tissue expander/implant/autologous flap] was performed by plastic surgery.
Nipple-Sparing Mastectomy
A nipple-sparing mastectomy was performed given [no nipple involvement on preoperative MRI / tumor > 2 cm from nipple]. An inframammary fold or lateral radial incision was used to preserve the nipple-areola complex. The retroareolar tissue was excised and sent as a separate margin specimen. Frozen section of the retroareolar tissue was [negative / positive, requiring nipple sacrifice]. The nipple-areola complex was preserved and incorporated into the reconstruction.
Modified Radical Mastectomy
A modified radical mastectomy was performed including axillary lymph node dissection (levels I and II). After completion of the mastectomy, the axillary contents were dissected. The axillary vein was identified as the superior border. The long thoracic nerve (medial) and thoracodorsal nerve (lateral) were identified and preserved. The axillary lymph node-bearing tissue from level I (lateral to pectoralis minor) and level II (posterior to pectoralis minor) was dissected en bloc. [Level III was accessed by dividing the costoclavicular ligament.] The specimen was removed. [___ lymph nodes were identified on immediate pathologic evaluation.] An axillary drain was placed.
Charting Tips
- Document laterality explicitly in the operative note header, body, and specimen label — wrong-site surgery in breast surgery is a sentinel event. Timeout should confirm laterality and it must be documented that the correct side was operated on.
- For sentinel lymph node biopsy, document: the tracer type and injection site, number of nodes removed, radioactive counts (ex vivo counts > background), and frozen section result — these elements are required for accurate pathologic staging.
- Skin flap thickness documentation matters for reconstruction planning and oncologic assessment. Document that adequate thickness (approximately 5-8 mm) was maintained and that no tumor was grossly visible in the flaps.
Billing Tips
- Bill 19303 for simple total mastectomy (14.63 wRVU, 90-day global). Use for total mastectomy without axillary dissection — skin-sparing and nipple-sparing mastectomy use the same code.
- Bill 19305 for radical mastectomy including pectoral muscles (17.02 wRVU) — rarely indicated in modern practice. Modified radical mastectomy (mastectomy + ALND without pectoral muscle removal) uses 19307 (17.59 wRVU).
- Axillary lymph node dissection (38740, 10.43 wRVU or 38745, 13.52 wRVU) is separately billable with modifier -51 when performed at the same setting as mastectomy. Document each as a distinct portion of the operative note.
- Immediate breast reconstruction (tissue expander placement 19357, 14.47 wRVU) is separately billable with modifier -51 when performed at the same operative setting. When plastic surgery performs the reconstruction, both surgeons bill their respective codes.
- 90-day global period: drain management, wound care, and surgical follow-up are bundled. Drain output logs, drain removal dates, and postoperative seroma aspiration in the office are not separately billable within the global period.