C7501 — Percutaneous breast biopsies using stereotactic guidance, with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, all lesions unilateral and bilateral (for single lesion biopsy, use appropriate code)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
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.
- For magnetic seed or SAVI SCOUT localization: documentation of depth and distance of seed/reflector relative to target on imaging (e.g., target-to-reflector distance), and any intra-operative probe localization findings.
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.
- Minimally invasive image-guided breast biopsy procedures are medically necessary as alternatives to needle localization core surgical biopsy (NLBx) in members with abnormalities identified by mammography that are non-palpable or difficult to palpate (e.g., deep, mobile, small [< 2 cm], or composed of clustered microcalcifications).
- Advanced Breast Biopsy Instrument (ABBI) for non-palpable or difficult-to-palpate mammographically-identified breast abnormalities.
2 Active Policies
AETNA-CPB-0269 — Breast Biopsy Procedures
A57848 — Billing and Coding: Tomosynthesis-Guided Breast Biopsy
Related Codes
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