2025 CPT code 19081
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Integumentary System Feed
Biopsy, breast, with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance.
Modifiers may be applicable. Modifier 50 is used for bilateral procedures.Other modifiers may be necessary to indicate specific circumstances.
Medical necessity for this procedure is based on the presence of a suspicious breast lesion requiring tissue diagnosis.The documentation should support the need for the biopsy, such as abnormal imaging findings or palpable abnormalities.
The physician performs the biopsy under stereotactic guidance, makes a small incision, removes tissue, may place localization device(s), and images the specimen (if performed). Post-procedure care includes applying pressure and bandages to the incision site.
In simple words: A needle biopsy of a breast lump is done using a special x-ray machine to help locate the lump.A small marker may be left in place to mark the spot, and pictures may be taken of the tissue sample.This code is used for the first lump sampled.
Under stereotactic guidance, the provider performs a percutaneous breast biopsy of a single lesion. This includes placement of a localization device (like a clip or metallic pellet) and imaging of the biopsy specimen, if performed. This code is for the first lesion biopsied.
Example 1: A patient has a suspicious breast lump detected on mammography. Stereotactic guidance is used to precisely locate the lump and obtain a tissue sample for diagnosis. A localization clip is placed to mark the biopsy site., A patient undergoes a stereotactic breast biopsy of a non-palpable lesion identified on ultrasound. Imaging of the biopsy specimen is performed to confirm successful tissue sampling., A patient has two suspicious lesions identified on a mammogram. The first lesion is biopsied using stereotactic guidance (19081). The second lesion is also biopsied stereotactically during the same session (19082).
Documentation should include the type of imaging guidance used, the number of lesions biopsied, placement of any localization devices, imaging of the specimen (if performed), and a description of the lesion(s).
- Specialties:Radiology, Breast Surgery, General Surgery
- Place of Service:Office, Hospital Outpatient Department, Ambulatory Surgical Center, and other outpatient settings