Coding and Billing Guidelines for Breast Biopsies

Section: Coding Billing

Last Reviewed: July 12, 2023

Applies To: Commercial and Medicaid Expansion

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 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

Coding

Coding Additional Lesions

Tomosynthesis Imaging Only

19499

19499-59

Stereotactic Imaging Only

19081

19082

Tomosynthesis & Stereotactic

19081

19082

Ultrasound

19083

19084

MRI

19085

19086

Without Guidance

19100 or 19101

Notes

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

Descriptions

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

19082

19083

19084

19085

19086

19100

Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure)

19101

Biopsy of breast; open, incisional

19499

Unlisted procedure, breast

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

American College of Radiology - Breast Imaging FAQ’s
Applied Radiology - Stereotactic Breast Biopsies
CMS - Billing and Coding: Tomosynthesis-Guided Breast Biopsy

History

Date

Updates

09/22/2021

Updated format

7/19/2022

Reviewed policy and updated cross reference for CMS – Billing and Coding: Tomosynthesis-Guided Breast Biopsy

7/12/2023

Annual policy review completed.

Disclaimer

Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.

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