Breast Cancer Surgery Chart

Key:
X = complete
* = partial
o = optional
• = see note under procedure

  Breast Pect. Major Pect. Minor Axillary Nodes Int Mam Nodes Other
Partial mastectomy without node *          
dissection (include lumpectomy, quadrantectomy, tylectomy, excisional biopsy, segmental resection, segmental mastectomy, nipple resection, wedge resection, wide excision, partial/less than total mastectomy, NOS)            
Partial mastectomy with node dissection (includes lumpectomy, quadrantectomy, tylectomy, excisional biopsy, segmental resection, segmental mastectomy, nipple resection, wedge resection, wide excision, partial/less than total mastectomy, NOS) *     x    
Subcutaneous mastectomy with/without node dissection *     o    
Simple (total) mastectomy without node dissection x          
Modified radical mastectomy or total/simple mastectomy with axillary dissection x */x   x    
Auchincloss' procedure x (retra-cted) x x    
Patey's procedure x (cut) x x    
Dyson's procedure x (cut) x x    
Radical mastectomy Halstead's procedure x x x x    
Extended radical mastectomy Urban procedure (infrequently performed)
• may include chest wall & ribs		 x x x x x •
Surgery of regional/distant sites/ nodes only       */x   x
Lymph node dissection (lymphadenectomy or lymph node sampling) (removal of at least 6 nodes for TNM staging)       x    

Removal of the following tissues may be ignored when determining the appropriate surgical code:

  • Fragments or tags of muscles
  • Fascia with no mention of muscle
  • Pectoralis minor muscle, pectoralis muscles, NOS

These procedures apply to unilateral resection of the breast. Simultaneous bilateral mastectomies are coded separately.

Code reconstructive surgery separately when the reconstruction is planned as part of the course of therapy. The reconstruction may be immediate or delayed; it is usually considered for Stage 0, I or II cases.