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A percutaneous breast biopsy is a minimally invasive procedure that allows for the sampling of breast tissue to diagnose potential abnormalities. This procedure is guided by stereotactic imaging, which employs a fixed coordinate system to accurately locate the lesion within the breast. The process begins with the cleansing of the skin and the administration of a local anesthetic to minimize discomfort. The stereotactic technique involves positioning the breast between a compression plate and a support structure, which stabilizes the lesion for precise targeting. The breast's thickness under compression is a critical factor in determining the depth of the lesion. An initial imaging study is performed at a perpendicular angle to the compression plate, which helps to center the lesion within the biopsy window. Subsequent images are taken at various angles to triangulate the lesion's position in three-dimensional space. When the biopsy needle is inserted into the lesion, multiple core needle insertions—typically between three to six—are performed to ensure an adequate tissue sample is collected. The obtained samples are then sent to a laboratory for pathological analysis. In cases where an automated vacuum-assisted or rotating biopsy device is utilized, the procedure involves nicking the skin and placing a probe at the lesion site. This device uses a vacuum to draw tissue into a sampling chamber, or a rotating cutting mechanism to capture tissue samples, with multiple samples taken in succession. Additionally, if a more extensive surgical procedure, such as a lumpectomy, is anticipated, a metallic localization clip or pellet is placed at the biopsy site to mark the exact location of the tissue removal. This is accomplished by leaving the biopsy needle in place while a plastic stylet with the clip or pellet is inserted and positioned using imaging guidance. After the clip or pellet is deployed, the needle and stylet are removed. Finally, additional imaging of the biopsy specimen may be performed before the tissue is sent for separate pathological examination. The coding for this procedure includes CPT® Code 19081 for the biopsy of the first lesion and CPT® Code 19082 for each additional lesion biopsied.
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The percutaneous breast biopsy with placement of localization devices is indicated for the following conditions:
The procedure for a percutaneous breast biopsy with localization device placement involves several detailed steps:
Following the biopsy procedure, the patient may experience some discomfort or bruising at the biopsy site. It is important to apply pressure to the site to minimize bleeding. Patients are typically advised to monitor the site for any signs of infection, such as increased redness, swelling, or discharge. Follow-up appointments may be scheduled to discuss the results of the pathological examination and any further necessary actions based on the findings. The localization device remains in place to assist in any subsequent surgical procedures, ensuring accurate identification of the biopsy site.
| Short Descr | BX BREAST ADD LESION STRTCTC | Medium Descr | BX BREAST W/DEVICE ADDL LESION STEREOTACT GUID | Long Descr | Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure) | Status Code | Active Code | Global Days | ZZZ - Code Related to Another Service | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 0 - No payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Items and Services Packaged into APC Rates | ASC Payment Indicator | Packaged service/item; no separate payment made. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1A - Major procedure - breast | MUE | 2 |
This is an add-on code that must be used in conjunction with one of these primary codes.
| 19081 | MPFS Status: Active Code APC J1 ASC G2 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 |
| LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | X5 | Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician | GC | This service has been performed in part by a resident under the direction of a teaching physician | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 77 | Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | AG | Primary physician | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CR | Catastrophe/disaster related | GA | Waiver of liability statement issued as required by payer policy, individual case | GZ | Item or service expected to be denied as not reasonable and necessary | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2014-01-01 | Added | Added |
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