Does 19499 require prior authorization?

No, 19499 does not require prior authorization (low confidence). No active coverage policies found for this code.

What is the Medicare reimbursement rate for 19499?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

HCPCS/CPT

No Prior Auth Required

No active coverage policies found for this code (low confidence)

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

For tomosynthesis-only procedures billed with CPT 19499, document the name of the procedure in the claim comments/narrative field: Part B — Loop 2400 SV101-7 for 837P (Item 19 for paper claims); Part A — Line SV202-7 for 837I electronic claims and Block 80 on the UB04 form.
Procedure notes must clearly document additional lesion(s) biopsied and specify which breast for each additional 19499 coded with modifier -59 or modifier -50.
If a different imaging modality is used during the same date of service, documentation must clearly support the clinical necessity to switch imaging modalities when modifier -59 is appended to the additional imaging CPT code.
Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; medical records documentation used for reviews (general statement from policy).

When digital breast tomosynthesis is the only imaging guidance used for a percutaneous core needle breast biopsy, bill CPT 19499 (Unlisted procedure, breast) and document the procedure name in the claim comments/narrative.
When tomosynthesis-only guidance is used to place a breast localization device (without biopsy), bill CPT 19499 with a clear description in the comments/narrative for Part A and Part B claims.
If a percutaneous breast biopsy is performed using both stereotactic and tomosynthesis imaging guidance, bill CPT 19081 for the first lesion (stereotactic guidance).
If more than one lesion is biopsied with tomosynthesis-only guidance on the same date of service, code an additional 19499 with modifier -59 for additional lesion(s) on the same breast, or use modifier -50 to indicate a bilateral procedure for lesions on the opposite breast.
Treatment for post-mastectomy complications including postoperative infection(s).
Breast reconstruction after Mastectomy with or without a diagnosis of cancer in accordance with the Women's Health and Cancer Rights Act of 1998 (reconstruction of the breast on which the Mastectomy was performed).

AMBETTER-CP.MP.31 — Cosmetic and Reconstructive Procedures

A57848 — Billing and Coding: Tomosynthesis-Guided Breast Biopsy

UHC-POL-breast-reconstruction — Breast Reconstruction

UMR-POL-UMR-breast-reconstruction — Breast Reconstruction

UMR-POL-UMR-cytological-examination-breast-fluids-cancer-screening — Cytological Examination of Breast Fluids for Cancer Screening or Diagnosis

Ask Verity about documentation requirements, denial risks, or coverage in your state.