The American Medical Association (AMA) has made a few important changes to CPT codes related to image-guided breast biopsies, and the most important thing, as explained below, is that some providers will not even be aware of them!
Shortly after AMA issued the 2015 CPT code update, it posted an errata sheet alerting providers to changes in reporting instructions for image-guided procedures:
- Breast biopsies (codes 19081-19086), including the placement of localization devices
- Placement of localization devices (codes 19281-19288) without biopsy
To better understand the changes for next year, it's important to understand the current instructions, which are discussed below.
2014 coding instructions
AMA included the following in CPT Assistant, May 2014 (underlines used for emphasis, not by AMA):
- Codes 19082, 19084, and 19086 are add-on codes used to report more than one image-guided biopsy using the same type of imaging guidance in the same breast; however, if additional biopsies are performed using different imaging modalities or if an image-guided biopsy using the same guidance modality of the opposite breast is performed, the primary codes from this code range (19081, 19083, 19085) are used for the first incidence of each different imaging modality.
- When reporting more than one localization device placement using different imaging modalities or using the same modality in the opposite breast, the primary codes (19281, 19283, 19285, 19287) from the code range are used for the first placement of localization device using each imaging modality.
2015 coding instructions
As stated above, for 2015, AMA changed the rules, though not in the 2015 CPT manual, which most providers have purchased, but in the errata sheet posted on its website shortly after the release of the CPT codes for next year. Providers who do not know about the errata sheet will not know about these very important revised instructions.
Changes that appear in the errata sheet include the following (the underlines were included by AMA):
- When more than one biopsy or localization device placement is performed using the same imaging modality, use an add-on code whether the additional service(s) is on the same or contralateral breast. If additional biopsies or localization device placements are performed using different imaging modalities, report another primary code for each additional biopsy or localization device placement performed using a different image guidance modality.
To report bilateral image-guided breast biopsies, report 19081, 19083, or 19085 for the initial biopsy. The contralateral and each additional breast image-guided biopsy are then reported with code 19082, 19084, or 19086.
Comparing 2014 and 2015
As an example, for 2014, AMA directions indicate that if one lesion in the left breast and one lesion in the right breast were biopsied, both using ultrasound guidance, they would be separately coded with 19083-50. Code 19084 would be assigned only if two lesions in the same breast were biopsied using the same modality:
- 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: Each additional lesion, including ultrasound guidance (list separately in addition to code for primary procedure)
For 2015, the coding would be as follows: If one lesion in the left breast and one in the right breast were biopsied using ultrasound guidance, codes 19083 and 19084 would be assigned -- instead of 19083-50 assigned in 2014. For 2015, the guideline to use modifier -50 for bilateral procedures now specifies its use with only the nonimage-guided or open biopsy codes.
A few other guidelines for 2015 may help with the assignment of codes 19081-19086, starting with the fact that the procedures identified by these codes include a clip or other localization device placement, as well as the imaging guidance and specimen radiography itself, when applicable:
- Note that imaging guidance to report breast biopsies varies by code, as follows:
- For stereotactic guidance, report codes 19081 and 19082.
- For ultrasound guidance, report codes 19083 and 19084.
- For MRI, report codes 19085 and 19086.
- Report each of the primary procedure codes (19081, 19083, 19085) only once per operative session.
- If additional biopsies are performed using different imaging modalities, report another primary code for each additional modality.
- If additional biopsies are performed using the same imaging modality on the same or contralateral breast, report an add-on code as appropriate.
The 2015 Medicare Physician Fee Schedule includes the relative value units (RVUs) shown in the following table.
|Relative value units by CPT code|
|CPT code||Nonfacility total RVU||Facility total RVU|
Under the 2015 hospital Outpatient Prospective Payment System (OPPS), the primary procedures have a status indicator (SI) of T, which CMS defines as "procedure or service, multiple procedure reduction applies." These procedures are paid under OPPS with a separate ambulatory payment classification (APC) payment.
No separate payment will be made for the add-on codes listed below which CMS assigned an SI of N -- items and services packaged into APC rates. However, note that even though these have no separate payment, their payment is packaged into payment for other services.
|Payments by status indicator and CPT code|
|CPT code||SI for OPPS||Payment rate|
Information source: On the Errata and Technical Corrections page of the AMA website, click on the link for "Errata and Technical Corrections in CPT 2015." The instructional changes included in the errata sheet can be found under the section titled "Category I, Integumentary System, Breast, Excision."
Jeff Majchrzak is vice president of clinical consulting services, radiology, for Panacea Healthcare Solutions. In his role as consultant, he conducts CPT coding assessments for both hospitals and physicians, evaluates administrative policies and procedures, and helps develop quality assurance programs to ensure complete and compliant coding and billing. Jeff trains both radiology and cardiology staff (on both technical and professional billing issues) in correct coding practices. Jeff contributes to numerous publications by MedLearn Publishing (a division of Panacea) and is a sought-after national speaker on coding and reimbursement for radiology, interventional radiology, nuclear medicine, and cardiology. Jeff can be reached at firstname.lastname@example.org, or visit Panacea Healthcare Solutions at www.panaceahealthsolutions.com.