Billing and Coding Article

Billing and Coding: Tomosynthesis-Guided Breast Biopsy

A57848

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Noridian Healthcare Solutions, LLC	A and B MAC	01111 - MAC A	J - E	California - Entire State
Noridian Healthcare Solutions, LLC	A and B MAC	01112 - MAC B	J - E	California - Northern
Noridian Healthcare Solutions, LLC	A and B MAC	01182 - MAC B	J - E	California - Southern
Noridian Healthcare Solutions, LLC	A and B MAC	01211 - MAC A	J - E	American Samoa Guam Hawaii Northern Mariana Islands
Noridian Healthcare Solutions, LLC	A and B MAC	01212 - MAC B	J - E	American Samoa Guam Hawaii Northern Mariana Islands
Noridian Healthcare Solutions, LLC	A and B MAC	01311 - MAC A	J - E	Nevada
Noridian Healthcare Solutions, LLC	A and B MAC	01312 - MAC B	J - E	Nevada
Noridian Healthcare Solutions, LLC	A and B MAC	01911 - MAC A	J - E	American Samoa California - Entire State Guam Hawaii Nevada Northern Mariana Islands

Article Information

General Information

Article ID
A57848

Article Title
Billing and Coding: Tomosynthesis-Guided Breast Biopsy

Article Type
Billing and Coding

Original Effective Date
01/01/2020

Revision Effective Date
01/01/2023

Revision Ending Date
N/A

Retirement Date
N/A

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Article Text

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Tomosynthesis-guided percutaneous core needle biopsy utilizes the technique of digital breast tomosynthesis or “3-D” mammography for identification of appropriate target sampling and intra-procedural needle placement. However, although digital breast tomosynthesis has become a more common screening and diagnostic modality; use of this technology for percutaneous breast biopsy is still on the rise. As a result, there may be uncertainty as to the proper coding and billing, since this procedure does not have a specifically assigned CPT code.

It is Noridian’s experience that the billing and coding of this procedure is at high risk for error. Therefore, Noridian is providing billing and coding guidance for providers who perform tomosynthesis-guided percutaneous biopsy for the evaluation of abnormal breast tissue concerning for malignancy.

If tomosynthesis is the only imaging guidance used for a breast biopsy, CPT code 19499 (Unlisted procedure, breast) should be utilized and the name of the procedure documented in the comments/narrative field for the following Part B claim field/types:

Loop 2400 or SV101-7 for the 5010A1 837P

Item 19 for paper claim

CPT code 19499 (Unlisted procedure, breast) should be utilized and the name of the procedure documented in the comments/narrative field for the following Part A claim field/types:
- Line SV202-7 for 837I electronic claim
- Block 80 for the UB04 claim form
Should more than one lesion of either breast be biopsied using tomosynthesis-only guidance on the same date of service, modifier 59 should be coded if the additional lesion is on the same breast (e.g. 19499 and 19499-59 should be coded to indicate 2 separate lesions undergoing tomosynthesis-guided breast biopsy) or modifier -50 indicating bilateral procedure, if repeated on the opposite breast. The additional lesion(s) requiring biopsy (including which breast) must be clearly documented in the procedure note. Multiple surgery payment rules applied.
If a percutaneous breast biopsy is performed using both stereotactic and tomosynthesis imaging guidance, 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) should be utilized.
Should it be clinically necessary to use additional non-mammography imaging guidance to biopsy a breast lesion(s) either of the same or opposite breast, on the same date of service, this procedure will be denied unless modifier -59 (e.g. 19499-59) is also coded along with the additional imaging modality respective CPT code. Documentation provided must clearly support the need to switch modalities. Examples include: ultrasound-guided percutaneous breast biopsy CPT 19083-19084, MRI-guided percutaneous breast biopsy CPT 19085-19086, percutaneous biopsy without imaging guidance CPT 19100, and open incisional biopsy CPT 19101.
In addition, CPT codes 19281-19288, related to the placement of a breast localization device (e.g. clip, metallic pellet, wire/needle, radioactive seeds) are not separately payable with 19499 as these procedure codes are considered part of the tomosynthesis-guided percutaneous breast biopsy procedure.
Similarly, if a tomosynthesis-only guided placement of a breast localization device procedure is performed (without biopsy), CPT 19499 will also need to be utilized with clear description in the comments/narrative field for both Part A and Part B claims.

Another issue is the common practice of obtaining a post-biopsy mammogram to confirm marker placement, assess for complications, etc. It is Noridian’s interpretation that a follow-up mammogram performed post tomosynthesis-guided breast biopsy will be considered part of the procedure and not separately payable, regardless of whether the patient is brought to a different room and/or unit for the mammography.

Post- biopsy mammograms (77065 and/or 77067, with or without G0279) coded and billed for the same date of service, regardless of the timing, separation, number, and/or order of claims billed, will not be considered separately payable.
Should either 19499 and/or 77065/77067 be coded and billed on separate claims, resulting in one of the codes being paid prior, additional payment by Noridian for the other billed service will be subject to payment adjustment and/or denial, taking previous payment into consideration.

References

Current Procedural Terminology (CPT) Manual
CPT Assistant 2019 - Frequently Asked Questions, December 2016, Volume 26, Issue 12, page 16

Response To Comments

Number	Comment	Response
1

Coding Information

Bill Type Codes

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Revenue Codes

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

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Group 1

(2 Codes)

Group 1 Paragraph

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Group 1 Codes

Code	Description
50	BILATERAL PROCEDURE: UNLESS OTHERWISE IDENTIFIED IN THE LISTINGS, BILATERAL PROCEDURES THAT ARE PERFORMED AT THE SAME OPERATIVE SESSION SHOULD BE IDENTIFIED BY ADDING THE MODIFIER -50 TO THE APPROPRIATE FIVE DIGIT CODE OR BY USE OF THE SEPARATE FIVE DIGIT MODIFIER CODE 09950
59	DISTINCT PROCEDURAL SERVICE: UNDER CERTAIN CIRCUMSTANCES, THE PHYSICIAN MAY NEED TO INDICATE THAT A PROCEDURE OR SERVICE WAS DISTINCT OR INDEPENDENT FROM OTHER SERVICES PERFORMED ON THE SAME DAY. MODIFIER -59 IS USED TO IDENTIFY PROCEDURES/SERVICES THAT ARE NOT NORMALLY REPORTED TOGETHER, BUT ARE APPROPRIATE UNDER THE CIRCUMSTANCES. THIS MAY REPRESENT A DIFFERENT SESSION OR PATIENT ENCOUNTER, DIFFERENT PROCEDURE OR SURGERY, DIFFERNET SITE OR ORGAN SYSTEM, SEPARATE INCISION/EXCISION, SEPARATE LESION, OR SEPARATE INJURY (OR AREA OF INJURY IN EXTENSIVE INJURIES) NOT ORDINARILY ENCOUNTERED OR PERFORMED ON THE SAME DAY BY THE SAME PHYSICIAN. HOWEVER, WHAN ANOTHER ALREADY ESTABLISHED MODIFIER IS APPROPRIATE IT SHOULD BE USED RATHER THAN MODIFIER -59. ONLY IF NO MORE DESCRIPTIVE MODIFIER IS AVAILABLE, AND THE USE OF MODIFIER -59 BEST EXPLAINS THE CIRCUMSTANCES, SHOULD MODIFIER -59 BE USED. MODIFIER CODE 09959 MAY BE USED AS AN ALTERNATE TO MODIFIER -59.

ICD-10-CM Codes that Support Medical Necessity

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

ICD-10-PCS Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code	Description
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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code	Description
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Other Coding Information

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion
			N/A	N/A

Non-Excluded CPT/HCPCS Ended Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation
01/01/2023	R2	Updated to indicate this article is not an LCD Reference Article.
01/01/2023	R1	Per 2023 CPT/HCPCS updates, HCPCS codes C7501 and C7502 were added to Group 1. Additionally, either the long or short description of CPT code 19499 has been updated.

Associated Documents

Updated On	Effective Dates	Status
11/08/2023	01/01/2023 - N/A	Currently in Effect	You are here
12/16/2022	01/01/2023 - N/A	Superseded	View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

Tomosynthesis
Breast
Biopsy
tomosynthesis-guided
percutaneous
imaging

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Billing and Coding: Tomosynthesis-Guided Breast Biopsy

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ICD-10-CM Codes that Support Medical Necessity

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Additional ICD-10 Information

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