Coding and Billing Guidelines for Breast Biopsy

Section: Coding Billing

North Dakota Blue Cross and Blue Shield (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) (eg, 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.”

Providers should only bill 19499 for breast biopsies performed using only tomosynthesis imaging guidance. Providers submitting unlisted codes must submit the following on the claim form:

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.

Breast Biopsies

Imaging Guidance Used

Tomosynthesis Imaging Only

Stereotactic Imaging Only

Tomosynthesis & Stereotactic

Ultrasound

MRI

Without Guidance

Codes

19499

19081

19081

19083

19085

19100
Or
19101

Additional Lesions

19499-59

19082

19082

19084

19086

 

Notes

Breast biopsy include:

  • Imaging
  • Placement of localization device(s)
  • Imaging of biopsy specimen, when performed

Bilateral Biopsies – Refer to the Bilateral Procedure Reimbursement Policy

 

Descriptions

19081

Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance

19082

Biopsy, breast, with placement of breast localization device(s) (eg, 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)

19083

Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance

19084

Biopsy, breast, with placement of breast localization device(s) (eg, 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

Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including magnetic resonance guidance

19086

Biopsy, breast, with placement of breast localization device(s) (eg, 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)

19100

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

19101

Biopsy of breast; open, incisional

19499

Unlisted procedure, breast

 

Resources

American College of Radiology

Breast Imaging FAQ’s

Applied Radiology

Stereotactic Breast Biopsies

Noridian

Billing and Coding: Tomosynthesis-Guided Breast Biopsy

Limitations and 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, 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.