In our last article, we discussed the differences between a partial mastectomy and excision of a breast mass and what documentation you would need to code each scenario. If you haven’t checked out that article, you can do so here:
http://codingmastery.com/2019/05/04/distinguishing-lumpectomies-and-excision-of-breast-mass/ .
Today, we are going to continue on the topic of surgeries of the breast with a discussion about image-guided percutaneous breast biopsies. The codes to report this procedure changed back in 2014, and coders often still have some questions about how to appropriately code this procedure as technology advances and physicians in different facilities perform part but not all of the work described by these codes.
Before we take a look at the codes, there are a few terms that you need to know to understand the code descriptions and guidelines for reporting this service:
- Percutaneous means to puncture through the skin.
- Stereotactic guidance in the context of these codes involves the use of low-dose mammogram images (aka x-rays of the breast) to locate a lesion for biopsy.
- Ultrasound guidance involves the use of ultrasound images to locate a lesion for biopsy
- MR guidance involves the use of magnetic resonance imaging (MRI imaging) to locate a lesion for biopsy.
- Tomosynthesis is an imaging technique that uses low-dose x-rays (i.e., mammogram images) along with computer reconstruction to create 3D images of the breast.
- A localization device is a device such as a clip or pellet that helps to identify an abnormality in the breast that is small and cannot be felt during an exam. These devices are used to help physicians locate these abnormalities for biopsy, removal, or future exams.
- Calcifications are calcium deposits in the breast that are visible on mammogram images. These calcium deposits may further be described as macrocalcifications (larger deposits of calcium) or microcalcifications (very tiny deposits of calcium).
- A mass or lesion is a generic term meaning an abnormal accumulation of tissue. We will use the term “lesion” to refer to all different abnormalities that may be found in the breast tissue for the remainder of this article, but definitions of specific types of abnormalities are provided here so you understand the difference in these terms when you see them in physician reports.
Now that we have our terminology down, let’s take a look at the CPT codes available for percutaneous biopsies of the breast:
- CPT 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.
- +CPT 19082: each additional lesion, including stereotactic guidance (list separately in addition to code for primary procedure).
- CPT 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.
- +CPT 19084: each additional lesion, including ultrasound guidance (list separately in addition to code for primary procedure).
- CPT 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.
- +CPT 19086: each additional lesion, including magnetic resonance guidance (list separately in addition to code for primary procedure).
As you can see, for each of the different types of imaging guidance that may be used during a percutaneous breast biopsy, we have one “parent code” to report the first lesion biopsied using that type of imaging guidance and then an add on code that is reported for each additional lesion biopsied using that same type of imaging guidance.
It’s also important to note that the physician “may” insert a localization device or “may” image the specimen that was removed to ensure the area of concern is included in the tissue removed. When these additional procedures are performed during the same encounter as the biopsy they are included in CPT codes 19081-19086 and should not be reported with separate CPT codes. These additional procedures though are not “required” to report these CPT codes. Anytime we see that a part of the code description is followed by the phrase “when performed” it is an optional service that may be performed but is not required in order to report the CPT code. The portions of the procedure description that must be performed to code CPT codes 19081-19086 is a percutaneous breast biopsy performed using the imaging guidance described by the code (e.g., stereotactic guidance).
Another important rule to know about these codes is how to report multiple biopsies during the same encounter. If more than one biopsy is performed using the same imaging guidance technique, you will report the parent code for the first lesion biopsied followed by the add on code for each additional lesion biopsied. This rule applies even if the two biopsies are in different breasts (i.e., a bilateral procedure with one procedure performed on the right breast and the other on the left). However, if multiple biopsies are performed during the same encounter and different image guidance techniques are used for each biopsy, you will report the parent code for each of the imaging techniques. For example, if a stereotactic-guided biopsy is performed on a lesion on the left breast and an ultrasound-guided biopsy on a lesion on the right breast, we would report CPT 19081 for the initial stereotactic biopsy on the left and CPT 19083 for the initial ultrasound guided biopsy on the right. Again it is the two different image guidance techniques that change how the case is coded.
Physicians have also started using tomosynthesis for guidance during percutaneous breast biopsies in recent years. Unfortunately, we do not have a code for performing a percutaneous breast biopsy using tomosynthesis. Some coders are inclined to report CPT codes 19081/19082 for a tomosynthesis-guided breast biopsy because this technique in part involves taking low dose x-rays (aka mammogram images). However, the remainder of the technique which involves using computer reconstruction with these mammogram images to create 3D images of the breast is not accurately described by these codes. The AMA has recommended reporting an unlisted code (CPT 19499) when tomosynthesis is the only image guidance technique used during the breast biopsy.
The CPT guidelines regarding image storage requirements were revised in 2019 to clarify that CPT codes in the surgery section of the CPT manual that include both the definitive procedure (e.g., biopsy) and image guidance or radiology supervision and interpretation (S&I) also require permanent storage of images from that imaging guidance or radiology S&I just as a radiology code for imaging guidance or radiology S&I alone would require permanent storage of images. The physician is not obligated to state in his/her report for the procedure that images were permanently stored, but this revision to the guidelines highlights the importance of having a conversation with your physicians or your coding management team to ensure that images are being permanently stored before reporting a code that requires this image storage.
As we have already discussed, CPT codes 19081-19086 all require the use of the imaging guidance listed in the code description to perform the biopsy. If a percutaneous needle biopsy of the breast is performed without the use of imaging guidance, report CPT 19100.
Finally, physicians will sometimes use image guidance to place a localization device without performing any biopsy of the breast during the same encounter. When the physician places a localization device alone without a percutaneous breast biopsy, report an appropriate code(s) from CPT range 19281-19288. We will not discuss these codes in detail in this article, but you can see a complete description in your CPT manual.
Let’s put this all together with a couple of examples to illustrate how to use these codes appropriately.
Example #1: The patient was brought back to the mammography suite and positioned appropriately on the stereotactic imaging table. Using stereotactic guidance the area of microcalcifications in the upper outer quadrant of the left breast was localized and a needle inserted into the area of concern. Three passes of the needle were performed to ensure an adequate specimen. After completion of the biopsy, the tissue removed was imaged and found to contain multiple clusters of microcalcifications confirming a successful biopsy. This concluded our procedure. Patient was instructed to call our office for a follow appointment in 7-10 days for results.
Coding for Example #1: The areas bolded in the note above are keys to our CPT coding. We first see that the physician is using “stereotactic guidance.” We then see that a single lesion (an area of microcalcifications in the upper outer quadrant of the left breast) was targeted for biopsy. We then see the physician passing a needle multiple times to get enough tissue while still using that stereotactic guidance. Note that even though “multiple passes” of the needle are made, the physician is still performing a biopsy of just one lesion/area of concern so this is still only counted as “one biopsy.” Finally, we see that the physician imaged the specimen removed to make sure it contained the microcalcifications. While this part of his procedure is not required per CPT guidelines, it is included when performed so we will not report any additional CPT code such as 76098 for this work. The CPT code supported for this procedure is CPT 19081.
Example #2: The patient was brought back to the interventional radiology suite. After sterile prep and drape, the area of calcifications in the right lower quadrant was imaged using MRI. The needle was then inserted using the MRI to guide the trajectory. Adequate tissue was obtained and a clip was inserted at the site of biopsy. Attention was then turned to a mass in the left inner upper quadrant. We brought in the ultrasound probe and localized the mass with a needle under ultrasound guidance. We obtained adequate tissue and concluded our procedure. Patient will follow up in 7-10 days for pathology results.
Coding for Example #2: The portions of the note above that are bolded are keys to our CPT coding. We see that the patient has an abnormality in the right lower quadrant. This initial lesion is approached with MRI guidance. We see the physician “inserting a needle using the MRI to guide the trajectory” (which confirms that the MRI is being used as guidance to get the needle to the right location). The physician then inserts a clip (a type of localization device) at the site of this biopsy. While inserting a localization device is not required to use this code, it is included when performed so we won’t report any additional code from range 19281-19288 for this work. We then see a second area of abnormality in the left inner upper quadrant. The physician switches from MRI guidance to ultrasound guidance during this second biopsy. We again see the ultrasound being used to “localize” (aka to locate) the mass and guide the needle into the mass. In this case, we will report CPT 19085 for the MRI guided biopsy on the right and CPT 19083 for the ultrasound guided biopsy on the left. Following our CPT guidelines, we will report the “parent code” for each lesion biopsied with a different type of imaging guidance.
