procedure code and description
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 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)
19083 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 – average fee payment – $700 – $720
19084 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 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
19086 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)
Breast Ultrasound
For characterization of a breast nodule the recommended CPT code is 76645 (Breast ultrasound).
For performing a line needle aspiration with imaging guidance use code 10022. A cyst drainage may be reported using 19000.
For breast biopsy, with placement of breast localization device(s) when performed and imaging of biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance use CPT code 19083 for the first lesion and if performed and +19084 for each additional lesion. Ultrasound guidance for these percutaneous procedures described above is included.
If performing a diagnostic breast ultrasound evaluation and an ultrasound guided needle procedure during the same patient encounter both codes may be billed: the diagnostic ultrasound (76645) and the ultrasound guided biopsy. Medicare CCI edits do not, at present, bundle the breast ultrasound and the ultrasound guidance of the biopsy, but some private payers may.
Breast
76645 Ultrasound Breast (unilateral or bilateral)
76880 Ultrasound Axilla
• For characterization of a breast nodule the recommended CPT code is 76645 (Breast ultrasound).
• For performing code 10022. A cyst drainage may be reported using 19000.
• For percutaneous needle core biopsy using imaging guidance use CPT code 19102.
• Ultrasound guidance of all percutaneous procedures described above should be reported separately. The recommended code is 76942.
• If performing a diagnostic breast ultrasound evaluation and an ultrasound guided needle procedure during the same patient encounter all three codes may be billed: the diagnostic ultrasound (76645), the ultrasound guidance (76942) and the biopsy (19102). Medicare CCI edits do not, at present, bundle the breast ultrasound and the ultrasound guidance of the biopsy, but some private payers may.
Bundled Services and Supplies and Modifiers 59 and XE, XP, XS, or XU
For dates of service on or after November 16, 2015, HCPCS code A4648 (tissue marker, implantable, any type, each) will not be eligible for separate reimbursement when reported with breast biopsy CPT codes 19081 – 19101 and/or placement of breast localization devices CPT codes 19281 – 19288. This information will be added to the Bundled Services and Supplies reimbursement policy. Modifiers will not override this edit therefore this information is also included in the Modifiers 59 and XE, XP, XS, & XU reimbursement policy.
CPT 76645 Ultrasound, breast(s) (unilateral or bilateral), real time with image documentation $ 90.04
APC 0265
Technical* $ 72.00 $ 49.74
Professional** $ 27.94
Global $ 99.95
BCBS bundling Guidliens
Added section for Allergen Immunotherapy. Added to the section Ultrasonic Guidance for Needle Biopsy – “Separate reimbursement is allowed for 76942 (Ultrasonic Guidance for Needle Biopsy) when submitted with 76645 (Ultrasound, Breast(s) (unilateral or bilateral), B-scan and or real time with image documentation). Removed the bundling guidelines for Hot or Cold Packs. Removed the bundling guidelines for Introduction of Needle or Intracatheter. Section contained information for CPT codes effective January 1, 2006. Removed the bundling guidelines under Casting Application and Strapping – “A4580, ‘cast supplies (e.g., plaster),’ will be considered incidental to casting/strapping codes 29000- 29799. The cost of the cast or splint is included in the basic value of the application and its corresponding code and does not provide separate reimbursement.”
Use of Modifiers
• indicating that only the professional service was provided, physicians must be attached to the CPT code for the ultrasound service. Payers will not reimburse physicians for the technical component in the hospital setting.
• If reporting a surgical procedure such as a biopsy on the same day E/M service must be “… above and beyond the usual preoperative and postoperative care associated with the procedure that was performed.” (CPT Assistant, May 2003.) Be sure to document in the patient’s record all components of the E&M service.
Billing Guidelines
Sentinel Node Biopsy (SNLB) CPT Codes for Breast Cancer/Melanoma
Coding Sentinel Node Biopsy (SNLB) is a surgical procedure in Melanoma and Breast Cancer Screening to determine if cancer has spread beyond a primary tumor into the lymphatic system. Sentinel Node Biopsy in Breast Cancer Evaluation reveals cancer spread, then the patient needs additional lymph nodes removed.
The Sentinel Nodes are the first few lymph nodes into which a tumor drains. Lumpectomy with Sentinel Node Biopsy for Melanoma involves injecting a tracer material that helps the surgeon locate the sentinel nodes during surgery. The sentinel nodes are removed and analyzed in a laboratory. If the sentinel nodes are free of cancer, then cancer isn’t likely to have spread and removing additional lymph nodes is unnecessary.
Sentinal node biopsy is not the same as Lymphadenectomy. Thus and confusing the two could have direct effects on the accuracy of your Medical Billing Claims.
Sentinel Node Biopsy (SNLB) CPT Coding
Please follow given points to be sure you get all your Sentinel Node Biopsy procedures billing claims reimbursed:
Sentinel Node Biopsy is Billable when Results Lead to Subsequent Excisions
When the surgeon performs a sentinel lymph node biopsy prior to an unplanned partial mastectomy (either with or without lymphadenectomy) and the subsequent excisions are a result of biopsy findings, you may report the sentinel node biopsy separately.
CPT Code 38525 and 38745 for Sentinel Node Biopsy (SNLB)
Sentinal Lymph Node Biopsy is separately reported when performed prior to a localized excision of breast or a mastectomy without Lymphadenectomy. Therefore you can report both sentinel lymph node biopsy and lymphadenectomy during the same session as long as:
The lymphadenectomy is unplanned at the time of the biopsy.
The decision to perform lymphadenectomy (at the same or a later session) is based on the results of the biopsy.
Example: The surgeon takes a biopsy of the sentinel axillary node (38525, Biopsy or excision of lymph node[s]; open, deep axillary node[s]). The pathology report indicates that the malignancy has spread, so the surgeon follows up with a lymphadenectomy (for example, 38745, Axillary lymphadenectomy; complete) to remove the affected tissue.
In above case, because the biopsy led to the decision to perform the mastectomy, you may report both 38525 and 38745.
Modifier 59 with CPT Code 38500-38530
Many payers will require that you append modifier 59 (Distinct procedural service) to the appropriate biopsy code (38500-38530) to further differentiate the procedure from the follow-up lymphadenectomy. In addition, your documentation should make clear that the biopsy results provided the justification for and led to the decision to perform the subsequent excisions.
CPT Codes for Sentinal Node Biopsy with Lymphadenectomy
You should not separately report Sentinal Node Biopsy (38500-38530) and a planned lymphadenectomy (38700-38780) in the same region during the same operative session. Instead, you should include the sentinel node biopsy in the more extensive, same-location lymphadenectomy. Medicare says:
Sentinal lymph node biopsy for malignant melanoma is eligible for reimbursement unless a regional lymphadenectomy is planned, regardless of the findings of the [biopsy].
If the surgeon prospectively plans to perform lymphadenectomy, you should not separately report a sentinel node biopsy. In this case, the complete lymphadenectomy automatically includes removal of any lymph nodes that would qualify as sentinel nodes.
You should consider sentinel node biopsy (38500-38530) to be a more “targeted” and less invasive procedure than lymphadenectomy (38700-38780).
The sentinel node is the first lymph node to receive drainage from a cancer-containing area of the breast (or other sites). If the sentinel lymph node is negative for metastases, the surgeon need not perform a complete lymphadenectomy (which removes a much greater volume of tissue), thereby avoiding the morbidity and complications associated with that procedure.
Keep in mind, however, that the above sequence of events would be rare. The purpose of a sentinel node biopsy is to avoid a lymphadenectomy, if possible. Therefore, surgeons generally perform lymphadenectomy only if the results of the sentinel node biopsy show malignancy.
CPT Codes for Excisions, not Incisions, Count for Sentinal Node
When the surgeon performs more than one sentinel lymph node biopsy, you should realize that the number of incisions, not the number of biopsies, determines the number of codes and/or units.
If the surgeon performs two biopsies through the same incision, you may report only a single code. If the surgeon takes three biopsies from two different incisions, you may report two codes, etc.
When reporting more than one biopsy code, append modifier 59 (Distinct procedural service) to the second and subsequent codes.
Example: Using one incision, the surgeon biopsies a superficial node and a deep axillary node. In this case, because the surgeon accesses the node through a single incision, you may report only the more extensive (higher-paying) code — in this case, 38525.
If the surgeon performs the same procedures through different incisions, you may report 38525 and 38500, attaching modifier 59 to the lesser (lower-valued) procedure here, 38500 to indicate a separate anatomic area.
Watch for Mastectomy/Lymphadenectomy Unbundle
If the surgeon performs a mastectomy and lymphadenectomy during the same session, you should report 19302 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]; with axillary lymphadenectomy) for the combined procedure rather than reporting 19301 and 38745 separately.
Often, with partial mastectomy, the surgeon will perform a limited axillary lymphadenectomy to remove some lymph nodes. The surgeon may also remove the nodes in the axilla through a separate incision at the same time.
Look out for the Staged Exception
Following some partial mastectomies (19301), the surgeon may return during the postoperative period to see if there has been any lymph node involvement and, if so, may choose to remove the nodes at that time.
In such a case, you would report the lymphadenectomy as a staged procedure using 38745 with modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) appended.
Sentinel Node Biopsy CPT Codes
Sometimes when performing a partial mastectomy it is necessary to remove axillary lymph nodes or biopsy the sentinel node. A sentinel node is the first node in a lymphatic chain to receive fluid from the primary tumor site which contains the metastasizing cancer cells.
CPT code 19301 is reported for a partial mastectomy or lumpectomy when the tumor is removed and specific attention is paid to the surgical margins. The lymph node excision code is determined by the type of procedure performed.
There are 3 levels of axillary lymph nodes Levels I-III. CPT code 38500 is reported for open excision or biopsy of superficial lymph nodes – these nodes are usually palpable under the skin. Levels II and III are deep and reported with CPT code 38525 (open, deep axillary nodes). The depth of dissection should be documented in the op note for coding accuracy.
Injection of dye to confirm a sentinel node is separately reported with CPT code 38792 (injection procedure for identification of sentinel node).
CPT code 19302 is only reported when “all identifiable axillary lymph nodes are removed” – A separate incision may be made but that is not what determines coding, reporting is based on the extent of axillary lymph node dissection.
Sentinel Node Biopsy ICD 9 Code
While coding Sentinel Node Biopsy/Surgery , the ICD 9 diagnosis code(s) must be represent the condition of the patient.
When the ICD-9-CM diagnosis codes 172.0-172.9 are used to identify malignant melanoma of the skin. The patient records must document that the tumor is Clinical Stage I.
When ICD-9-CM codes 174.0-174.9, 175.0, or 175.9 are used to identify breast cancer, the patient records must document that the tumor is Clinical Stage I or II.
IDTF Table for CPT Codes 19081-19086
CPT Code Modifier Physician Supervision Level
19081 TC, 26 Ultrasound is bundled 2
19082 TC, 26 Ultrasound is bundled 2
19083 TC, 26 Ultrasound is bundled 2
19084 TC, 26 Ultrasound is bundled 2
19085 TC, 26 Ultrasound is bundled 2
19086 TC, 26 Ultrasound is bundled 2
Code NFAC Fee FAC Fee
10030
$614.61
$115.92
19081
$523.39
$132.54
19082
$428.83
$64.01
19083
$520.89
$124.38
19084
$423.33
$60.22
19085
$793.48
$145.35
19086
$640.57
$67.16
Reimbursement Guidelines Nonpalpable Breast Lesions
Effective January 1, 2003, Medicare covers percutaneous image-guided breast biopsy using stereotactic or ultrasound imaging for a radiographic abnormality that is nonpalpable and is graded as a BIRADS III, IV, or V. Palpable Breast Lesions Effective January 1, 2003, Medicare covers percutaneous image guided breast biopsy using stereotactic or ultrasound imaging for palpable lesions that are difficult to biopsy using palpation alone. Contractors have the discretion to decide what types of palpable lesions are difficult to biopsy using palpation.
CPT Code Description
10022 Fine needle aspiration; with imaging guidance
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 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)
19083 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
19084 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 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
19086 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)
Non-Facility Payment Facility Payment APC Code APC Payment
10022 Fine needle aspiration; with imaging guidance $136.83 $64.67 0004 $320.01
19000 Puncture aspiration of cyst of breast $109.94 $43.70 0004 $320.01
19102 Biopsy of breast, percutaneous, needle core, using imaging guidance $212.05 $101.43 0005 $570.59
19103 Biopsy of breast, percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance $548.35 $189.59 0037 $1073.79
19290 Preoperative placement of needle localization wire, breast $159.64 $63.65 Packaged
Service No Payment
19295 Image guided placement of metallic localization clip or marker during biopsy $91.22 No Payment Packaged Service No Payment
60100 Biopsy, thyroid, percutaneous core needle $110.96 $78.97 0004 $320.01
ICD-10-CM and ICD-10-PCS
ICD-10-CM (diagnosis) and ICD-10-PCS (procedure) codes were implemented October 1, 2015. It is the physician’s ultimate responsibility to select the codes that appropriately represent the service performed, and to report the ICD-10-CM code based on his or her findings or the pre-service signs, symptoms or conditions that reflect the reason for doing the mammography. Examples are provided of ICD-10-CM diagnosis and ICD-10-PCS procedure codes that relate to breast ultrasound procedures for breast cancer screening.
ICD-10-CM (diagnosis)
• R92.0 Mammographic microcalcification found on diagnostic imaging of breast
• R92.1 Mammographic calcification found on diagnostic imaging of breast
• R92.2 Inconclusive mammogram
• R92.8 Other abnormal and inconclusive findings on diagnostic imaging of breast
• Z12.39 Encounter for other screening for malignant neoplasm of breast
ICD-10-PCS
• BH40ZZZ Ultrasonography of Right Breast
• BH41ZZZ Ultrasonography of Left Breast
• BH42ZZZ Ultrasonography of Bilateral Breasts
