General Surgery Coding Alert

Question: What code(s) should we use when the surgeon performs a "stereotactic needle core biopsy" of breast tissue?

Florida Subscriber

Answer: You should report the code for a needle core breast biopsy with guidance -- 19102 (Biopsy of breast; percutaneous, needle core, using imaging guidance). "Stereotactic" refers to an imaging process to locate the lesion in three dimensions and direct the biopsy apparatus to that spot. Although CPT provides another code for breast needle core biopsy (19100, Biopsy of breast; percutaneous, needle core, not using imaging guidance [separate procedure]), you shouldn't use it when you see the term "stereotactic" in the procedure description.

Check biopsy mechanism: Not all stereotactic breast biopsies are needle core. The surgeon might remove the targeted lesion by using a more sophisticated device that has suction or rotating action to obtain the sample. In those cases, you should report 19103 (Biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance).

Imaging is separate: If the surgeon performs the stereotactic guidance you should list that service separately using 77031 (Stereotactic localization guidance for breast biopsy or needle placement [e.g., for wire localization or for injection], each lesion, radiological supervision and interpretation). Append modifier 26 (Professional component) if your surgeon does not own the imaging equipment.

Caution: If a radiologist, not your surgeon, performs the stereotactic guidance, you should only report the surgical code.