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.

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.