Article - Billing and Coding: Tomosynthesis-Guided Breast Biopsy (A57849)

CMS National Coverage PolicyN/AArticle TextThis article is effective immediately.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 Noridians 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 followingPart Bclaim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimCPT code 19499 (Unlisted procedure, breast) should be utilized and the name of the procedure documented in the comments/narrative field for the followingPart Aclaim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formShould 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 bothPart A and Part Bclaims.Another issue is the common practice of obtaining a post-biopsy mammogram to confirm marker placement, assess for complications, etc. It is Noridians 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.ReferencesCurrent Procedural Terminology (CPT) ManualCPT Assistant 2019 - Frequently Asked Questions, December 2016, Volume 26, Issue 12, page 16