Radiology Coding Alert

In order to lessen coding confusion, code 19101 was recently introduced so breast imaging practices could receive reimbursement that accurately reflects the increased physician time and associated costs of emerging technologies. But coders must understand the circumstances that distinguish two of the most common codes: 19100 (biopsy of breast; needle core [separate procedure]) and 19101 (biopsy of breast; incisional [separate procedure]).

Historically, CPT Code 19100 had been assigned to the procedural component of virtually all breast biopsies. However, the relatively recent emergence of stereotactic instruments has made it possible to biopsy small, nonpalpable lesions for definitive diagnosis. The advent of this new technique necessitated a corresponding procedural code19101.

The Health Care Financing Administration (HCFA) advised Medicare carriers that surgical code 19101 had been added to reflect the new biopsy techniques made possible by stereotactic technology. It noted that 19101 should be used to report image-guided incisional biopsies of nonpalpable breast lesions. Organizations such as the American College of Radiology (ACR) lobbied heavily for this new code because it more accurately reflects the additional physician time and higher costs (i.e. supplies, technology) related to stereotactic breast core biopsies of this nature.

The use of 19101 is not restricted in any way by the type of surgical devise used (i.e. core needle, mammotome), according to the ACR.

In addition, it reports that needle core biopsies of palpable lesions using needles such as Tri-cut should continue to be reported with CPT code 19100.

Three Areas of Confusion

Following is an example of a core needle biopsy, performed with stereotactic guidance. It has correctly been assigned CPT code 19100 (accompanied by radiologic supervision and interpretation [RS&I] code 76095) because the procedure is not incisional.

HISTORY: Clustered microcalcifications in the left breast

BREAST CORE BX

FINDINGS: After obtaining informed consent and explaining to the patient the whole procedure, a left breast stereotactic core biopsy was performed using a 14-gauge needle for the biopsy. The patient tolerated the procedure without any difficulty. Post-biopsy instructions were given to the patient.

IMPRESSION: Left breast stereotactic core needle biopsy for calcifications. A separate report from the pathology department shows focal presence of highly atypical intraductal lesion associated with microcalcifications regraded as intraductal carcinoma with high nuclear grade. No invasion. Deeper sections will be obtained and an addendum from the pathology department will be issued.

ICD-9 793.8

BI-RADS: (4) Suspicious abnormalitybiopsy should be considered

CPT: 19100/76095

1. A significant area of confusion surrounding these two codes is the definition of incisional as it appears in CPT code 19101. According to the American Medical Association (AMA), an incisional biopsy of the breast represents an open surgical biopsy, not the typical stick approach for a needle core biopsy. In addition, a stab wound type of incision of the skin on the breast to allow easier penetration of a core needle also would not constitute an incisional biopsy. Code 19100 should be used in these instances.

The radiological supervision and interpretation codes that would accompany breast biopsies are 76095 (stereotactic localization for breast biopsy, each lesion, radiological supervision and interpretation) or 76942 (ultrasonic guidance for needle biopsy, radiological supervision and interpretation), depending on which modality is used.

2. CPT 1999 and the upcoming CPT 2000 notes that both surgical codes 19100 and 19101 describe unilateral procedures. If the procedures are performed bilaterally, the appropriate codes should be reported with the -50 modifier (bilateral procedure), or an RT/LT (right/left) designation, depending on your local carriers preference.

3. Confusion surrounds the number of times CPT codes 19100, 19101 and 76095 may be assigned. According to the CPT manual, these codes may be assigned once for each lesion biopsied, but not for each pass that the needle or sampling device makes into each lesion. If multiple lesions on one breast are biopsied, the appropriate code for the first lesion should be reported once. This code, plus a -51 modifier (multiple procedures), should then be assigned for the second and any subsequent lesion on each breast. Another option, depending on specific carrier requirements, would be to list the base code and enter the number of lesions biopsied in the units field of the billing form.

Occasionally during a stereotactic breast core biopsy of a nonpalpable lesion, all mammographic evidence of abnormality may be removed. When a physician biopsies and removes the same lesion, coders would assign CPT 19120 (excision of cyst, fibroadenoma, or other benign or malignant tumor aberrant breast tissue, duct lesion, nipple or areolar lesion [except 19140], male or female, one or more lesions), with the appropriate radiology supervision and interpretation code.

If the physician removes one lesion, and biopsies others on the same breast, code 19120 would be assigned for the removal, along with 19101-59 to indicate that the biopsy was performed on a lesion other than the one removed.

The -59 modifier (distinct procedural service) documents that the additional biopsies were distinct and separate procedural services performed on the same day, adds Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, SC.

According to the ACR, if the radiologist places a titanium clip during the biopsy to mark the potentially diseased area in case follow-up surgery or localized radiation is needed, coders may add 19290 (preoperative placement of needle localization wire, breast).

However, no radiology supervision and interpretation (RS&I) code should be assigned for the clip placement, since this is covered in the original biopsy supervision and interpretation code.

In addition, the ACR says CPT 76098 (radiological examination, surgical specimen) may be coded in addition to the base procedure if radiographs of the biopsy specimen are performed to ensure the tissue contains a sample of the abnormality.

Editors note: Rebecca A. Zuurbier, MD, director of the Betty Lou Ourisman Breast Health Center at the Lombardi Cancer Center, Georgetown University Medical Center in Washington, DC, helped in the development of this article.