76098
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.30
Facility
$16.64
Non-Facility
$16.64
Documentation Required
- 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.
- The IDTF must have Palmetto GBA provider enrollment approval listing the specific CPT/HCPCS codes the facility is authorized to bill for Medicare beneficiaries.
Key Coverage Criteria
- 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.
- An IDTF must be credentialed and approved by Palmetto GBA provider enrollment to bill Medicare for a specific diagnostic procedure or material.
- Additional services and supplies (e.g., radiopharmaceuticals, special contrast agents, medications) are payable to an IDTF when the diagnostic test itself is payable and the supplies are commonly separately reimbursed to a physician in an office setting.
9 Active Policies
L33693 — Peripheral Venous Ultrasound
J09
A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)
J12
L37371 — Electroretinography (ERG)
J12
L35007 — Vestibular and Audiologic Function Studies
J12
L35434 — Oximetry Services
Related Codes
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