This document provides coding and billing guidelines for breast biopsies.
Coding & Billing Guidelines
Blue Cross Blue Shield of North Dakota (BCBSND) has identified an increase in providers billing Current Procedural Terminology (CPT) 19499, Unlisted Procedure, Breast. Review of medical records identified 19499 was being used for breast biopsies performed with stereotactic and tomosynthesis image guidance.
The American Medical Association (AMA)/ American College of Radiology (ACR) Clinical Examples in Radiology Fall 2016 issue, provides guidance on the reporting of both a stereotactic and tomosynthesis imaging-guided core breast biopsy as follows:
“When a breast biopsy is performed using both stereotactic and tomosynthesis imaging guidance, it is appropriate to use CPT code 19081, Biopsy, breast, with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance.
If a combination stereotactic–tomosynthesis guided biopsy is performed using a separate piece of equipment (such as a prone table) and the patient is moved to another unit for a post-procedure mammogram, it is appropriate to report the post-procedure mammogram separately. If the combination stereotactic–tomosynthesis guided biopsy is performed using a standard digital breast tomosynthesis mammography unit on which the post-procedure mammogram is also obtained, it is not appropriate to report the post-procedure mammogram separately.”
Note: Providers should only bill 19499 for breast biopsies performed using only tomosynthesis imaging guidance.
Providers submitting unlisted codes must submit the following
CMS-1500 Claim Form
- For electronic claim submission, include a detailed description of the service performed in the SV101-7 or the 2400 service line loop.
- For paper claim submission, include a detailed description of the service performed in Box 19.
UB04 Claim Form
- For electronic claim submission, include a detailed description of the service performed in the SV202-7.
- For paper claim submission, include a detailed description of the service performed in Box 80.
Imaging Guidance Used
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Coding
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Coding Additional Lesions
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Tomosynthesis Imaging Only
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19499
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19499-59
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Stereotactic Imaging Only
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19081
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19082
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Tomosynthesis & Stereotactic
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19081
|
19082
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Ultrasound
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19083
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19084
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MRI
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19085
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19086
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Without Guidance
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19100 or 19101
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Notes
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Breast biopsies include:
- Imaging
- Placement of localization device(s)
- Imaging of biopsy specimen, when performed
Note: Bilateral Biopsies – Refer to the Bilateral Procedure Reimbursement Policy
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Descriptions
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19081
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Biopsy, breast, with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance
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19082
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Biopsy, breast, with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure)
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19083
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Biopsy, breast, with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance
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19084
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Biopsy, breast, with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure)
|
19085
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Biopsy, breast, with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including magnetic resonance guidance
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19086
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Biopsy, breast, with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including magnetic resonance guidance (List separately in addition to code for primary procedure)
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19100
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Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure)
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19101
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Biopsy of breast; open, incisional
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19499
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Unlisted procedure, breast
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Limitations & Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross References
History
Date
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Updates
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09/22/2021
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Updated format
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7/19/2022
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Reviewed policy and updated cross reference for CMS – Billing and Coding: Tomosynthesis-Guided Breast Biopsy
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7/12/2023
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Annual policy review completed.
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5/31/2024
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Annual policy review completed. Added definition of (CPT) Current Procedural Terminology
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