CPC

12 Aug 2016

Breast Biopsy Coding Guidelines


Ultrasound-Guided Breast Biopsy:


If Biopsy of the breast is performed using ultrasound guidance, then we have to assign CPT 19083 (first lesion) and 19084 (additional lesions biopsied), No need to add ultrasound guidance code as like previously we used to code, now it is inclusive with the surgery procedures.

 

-          CPT 19083: Biopsy, breast, with the 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

 

-          + CPT 19084: Biopsy, breast, with the 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). MUE: 2 Units     

 

       ·         Localization device placement and specimen imaging are not required for this code, but they are included if performed.

 

       ·         These codes include ultrasound guidance.  

 

How to code Ultrasound-guided breast biopsy: Eg,


                     1. Single lesion  – 19083

                     2. Two lesions    – 19083, 19084

                     3. Three lesions  – 19083, 19084 x 2

 

Note: No need to add CPT 76942 (US) it’s included with the CPT 19083.

 

Ultrasound-Guided Breast Cyst Aspiration:

If breast cyst aspiration is performed by using ultrasound guidance, then we have to assign CPT 19000 (first breast cyst) for additional cysts use CPT (19001). These codes should be followed by guidance code, for eg, CPT 76942 (Ultrasound guidance).

              

          -          CPT 19000: Puncture aspiration of cyst of the breast, first cyst

 

          -          + CPT 19001: Puncture aspiration of cyst of the breast; each an additional cyst (List separately in addition to code for primary procedure). MUE: 5 Units          

 

·         If the provider performs the procedure under image guidance, then we should use the appropriate guidance code such as CPT 76942 for ultrasound or CPT 77021 for magnetic resonance imaging along with CPT 19000.

 

How to code ultrasound-guided breast cyst aspiration: Eg,

                
                   1. Single cyst – 19000, 76942

                        2. Two cysts   – 19000, 19001, 76942

                        3. Three cysts - 19000, 19001 x 2, 76942

     How to code MRI guided breast cyst aspiration: Eg,

                
                   1. Single cyst – 19000, 77021

                        2. Two cysts   – 19000, 19001, 77021

                        3. Three cysts - 19000, 19001 x 2, 77021

 

 Note: For Ultrasound-guided FNA (Fine Needle Aspiration) 10005 & 10006

 

Ultrasound-Guided Placement of localization device:

      

-          CPT 19285: Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including ultrasound guidance

      

-          + CPT 19286: Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure), MUE: 2 Units         

 

·         These codes include ultrasound guidance.  

 

How to code: Eg,

                  Single lesion – 19285

                  Two lesions    – 19285, 19286

                  Three lesions – 19285, 19286 x 2

 

Note: No need to add CPT 76942 (US) it’s included with the CPT 19285

 

Stereotactic Guided Breast Biopsy:

 

-          CPT 19081: Biopsy, breast, with the 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.

 

Note: When a provider performs more than one breast biopsy using the same imaging modality, use add on code whether the additional service is on the same or contralateral breast. 

 

For example, for each additional lesion biopsied under stereotactic guidance whether the additional lesion is on the same or contralateral breast, Use +19082.

 

If the physician performs the additional biopsies using different imaging modalities, report another primary code for each additional modality.

 

-          + CPT 19082: Biopsy, breast, with the 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). MUE: 2 units                 

    

·         These codes include stereotactic guidance.

 

How to code: Eg,

                    Single lesion – 19081

                    Two lesions    – 19081, 19082

                    Three lesions – 19081, 19082 x 2

 

Stereotactic Guided Placement of Localization device in Breast:

 

-          CPT 19283: Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including stereotactic guidance.

 

-          + CPT 19284: Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure). MUE : 2 Units   

 

·         These codes include stereotactic guidance.

 

How to code: Eg,

                  Single lesion – 19283

                  Two lesions    – 19283, 19284

                  Three lesions – 19283, 19284 x 2

 

MRI Guided Breast Biopsy:

 

-          CPT 19085: Biopsy, breast, with the 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

 

-          CPT 19086: Biopsy, breast, with the 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), MUE : 2 Units  

 

·         These codes include MRI guidance.

 

How to code: Eg,

                      Single lesion – 19085

                      Two lesions    – 19085, 19086

                      Three lesions – 19085, 19086 x 2

 

MRI Guided Placement of Localization device:

 

-          CPT 19287: Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including magnetic resonance guidance

 

-          CPT 19288: Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including magnetic resonance guidance (List separately in addition to code for primary procedure), MUE : 2 Units                       

 

·         These codes include MRI guidance.

 

How to code: Eg,

                   Single lesion – 19287

                   Two lesions    – 19287, 19288

                   Three lesions – 19287, 19288 x 2

 

Note: To report bilateral image-guided breast biopsies, report 19081, 19083, or 19085 for the initial biopsy. The contra-lateral and each additional breast image guided biopsy are then reported with code 19082, 19084 or 19086.

 

Breast biopsies, without image guidance, are reported with CPT 19100 and 19101.

   

-          CPT 19100: Biopsy of the breast; percutaneous, needle core, not using imaging guidance (separate procedure), MUE: 4 Units

           

·         When the provider performs a biopsy on more than one site on the same side, report the subsequent biopsies with modifier 59.

 

·         -          CPT 19101: Biopsy of the breast; open, incisional, MUE: 3 Units

 

Incisional biopsy is different from an excisional biopsy. An incisional biopsy, the provider removes only a small lump that she sends to pathology for further analysis; an excisional biopsy involves removal of the entire lump.  

 

 

 Points to be remembered:

  • When more than one biopsy or localization device placement is performed using the same imaging modality, use an add-on code whether the additional service(s) is on the same or contralateral breast. 

  • If additional biopsies or localization device placements are performed using different imaging modalities, report another primary code for each additional biopsy or localization device placement performed using a different image guidance modality.

  • Do not report 19281-19288 in conjunction with 19081-19086, 76942, 77002, and 77021 for same lesion.