Bx breast 1st lesion strtctc

CPT 19081 covers a breast biopsy of the first suspicious area using stereotactic imaging guidance (3D mammography or computer-guided positioning). This is typically done when a mammogram shows a concerning spot that cannot be felt during a physical exam.

Showing rates for

National Average

Base Medicare rate

$470.97

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

3.29

PE RVU (NF)

10.94

MP RVU

0.33

Total RVU

14.56

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Always verify site of service before scheduling—non-facility setting yields $470.97 versus hospital facility at $155.91, a $315.06 difference per procedure
Impact: $315.06 revenue difference per case based on setting; significant impact on practice revenue for high-volume breast centers
Bill 19081 only for the FIRST lesion biopsied; use add-on code 19082 for each additional lesion in same breast or 19083 for additional lesions when using ultrasound guidance
Impact: Incorrect use of 19081 for multiple lesions instead of proper add-on codes results in denial of additional lesion payment (approximately $100-150 per missed add-on)
Document stereotactic guidance separately from the biopsy technique; medical necessity requires clear documentation that lesion was non-palpable and required stereotactic localization
Impact:
Bill specimen radiography (76098) separately when performed to confirm adequate sampling of calcifications; this is not bundled into 19081
Impact: Captures additional $43-67 per procedure when calcifications are targeted; frequently overlooked ancillary revenue
Ensure modifier LT or RT is appended on every claim; laterality is required by Medicare and most commercial payers for breast procedures
Impact: Missing laterality modifier results in automatic claim rejection requiring resubmission, delaying payment 30-45 days
When patient has both diagnostic mammogram and biopsy same day, append modifier 59 to prevent inappropriate bundling denials
Impact: Prevents loss of diagnostic imaging payment ($150-250) that payers may bundle incorrectly without proper modifier use

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 19081 in 2025?

The 2025 Medicare national average reimbursement for CPT 19081 is $470.97 in non-facility settings (office, ASC) and $155.91 in facility settings (hospital outpatient). The significant difference reflects the practice expense of maintaining stereotactic equipment in office-based settings versus hospital departments.

Can I bill CPT 19081 for multiple breast lesions biopsied during the same session?

No, CPT 19081 is only billed once for the first lesion biopsied using stereotactic guidance. For each additional lesion biopsied in the same breast during the same session, use add-on code 19082. If additional lesions are biopsied using ultrasound guidance instead, use 19083. Billing 19081 multiple times will result in denial.

What modifiers are required when billing CPT 19081?

Laterality modifiers LT (left) or RT (right) are mandatory for CPT 19081 and omission results in automatic claim denial. Additionally, modifier 59 may be needed when billing with same-day diagnostic imaging to prevent bundling, and modifier 50 for bilateral procedures when biopsying first lesion in each breast.

How many RVUs is CPT 19081 worth in 2025?

CPT 19081 has a total of 14.56 RVUs in 2025, consisting of 3.29 work RVUs, 10.94 non-facility practice expense RVUs (1.2 facility PE RVUs), and 0.33 malpractice RVUs. This relatively high RVU value reflects the technical skill and equipment required for stereotactic-guided procedures.

What is the difference between CPT 19081 and 19083?

CPT 19081 is for biopsy of the first breast lesion using stereotactic (mammographic) guidance, while 19083 is an add-on code for biopsy of each additional lesion using ultrasound guidance during the same session. The codes differ in both the imaging modality used for guidance and whether they represent the primary or additional lesion.

Does CPT 19081 include the imaging guidance or is that billed separately?

CPT 19081 is an all-inclusive code that includes the stereotactic imaging guidance, needle insertion, tissue sampling, and marker placement. You should not separately bill for the stereotactic guidance itself. However, specimen radiography (76098) to confirm adequate sampling can be billed separately as it is not bundled.

What documentation is needed to support medical necessity for CPT 19081?

Medical necessity documentation must include a BI-RADS 4 or 5 classification from mammography, confirmation that the lesion is non-palpable requiring image guidance, specific lesion location and characteristics, and clear clinical indication for tissue diagnosis. Missing BI-RADS classification or inadequate imaging documentation are leading causes of medical necessity denials.