Bx breast 1st lesion us imag

CPT 19083 covers an ultrasound-guided biopsy of the first breast lesion, where a radiologist or surgeon uses ultrasound imaging to precisely guide a needle to remove tissue samples from a suspicious area in the breast for testing.

Showing rates for

National Average

Base Medicare rate

$465.79

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

3.1

PE RVU (NF)

MP RVU

0.3

Total RVU

14.4

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

NCCI bundling edits

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Billing tips

Verify place of service correctly—POS 22 (outpatient hospital) triggers facility rate of $146.53 while POS 11 (office) triggers non-facility rate of $465.79
Impact: Incorrect POS coding results in $319.26 reimbursement difference and potential recoupment audits
Bill 19084 for each additional lesion biopsied in same breast or contralateral breast during same session; do not repeat 19083
Impact: Prevents denials for duplicate billing and captures additional reimbursement of approximately $88-$280 per additional lesion depending on setting
Document ultrasound guidance separately in operative note with permanently stored images showing needle placement; guidance is bundled into 19083 and should not be separately coded
Impact: Prevents unbundling denials from billing 76942 separately, which would trigger -$150 to -$200 recoupment plus potential fraud scrutiny
Include clip placement documentation if performed; this is bundled into 19083 but must be documented to support the full RVU value of 14.4
Impact: Lack of clip documentation may trigger downcoding during audits, particularly for commercial payers who may reduce payment by 15-20%
Confirm pathology report matches biopsy site documented in operative note; discrepancies trigger medical necessity denials
Impact: Laterality or location mismatches result in automatic denials requiring appeals with corrected documentation, delaying payment 45-90 days
For Medicare patients, ensure referring provider has valid NPI and ordering documentation meets Appropriate Use Criteria for breast imaging
Missing or invalid referring provider information triggers automatic denial under Medicare's imaging AUC requirements effective 2025

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Frequently asked questions

What is the Medicare reimbursement for CPT 19083 in 2025?

Medicare pays $465.79 for CPT 19083 in non-facility settings (physician office) and $146.53 in facility settings (hospital outpatient department) based on the 2025 national average rates. Actual payment varies by geographic locality and MAC jurisdiction.

Can I bill CPT 19083 for each breast lesion biopsied?

No, CPT 19083 is only used for the first lesion biopsied during a session. For each additional lesion in the same or contralateral breast during the same encounter, use add-on code 19084. Billing multiple units of 19083 will result in denials for duplicate services.

Is ultrasound guidance separately billable with CPT 19083?

No, ultrasound guidance (CPT 76942) is bundled into 19083 and cannot be billed separately. The code descriptor specifies 'us imag' (ultrasound imaging) is included. Billing both codes together violates NCCI edits and will trigger denials and potential recoupment.

What RVU value does CPT 19083 have?

CPT 19083 has a total RVU of 14.4 for 2025, consisting of 3.1 work RVUs, 11.0 practice expense RVUs (non-facility), 1.13 practice expense RVUs (facility), and 0.3 malpractice RVUs. The high PE differential explains the large payment gap between settings.

Do I need a modifier for bilateral breast biopsies?

Use modifier 50 when performing first lesion biopsy in both breasts during the same session, or use RT/LT modifiers separately on two line items depending on payer preference. Most Medicare contractors prefer RT/LT with 150% payment for bilateral procedures. Always check your MAC's specific billing guidelines.

How do I bill when a clip is placed during the biopsy?

Clip placement is included in CPT 19083 and should not be coded separately. Document clip placement in the operative note to support the complete procedure, but do not add codes like 19281-19288 (clip placement codes) which are for different procedures. The reimbursement for 19083 already accounts for clip placement.

What documentation prevents denials for CPT 19083?

Essential documentation includes pre-procedure imaging showing the lesion with BI-RADS assessment, real-time ultrasound guidance notation during biopsy, number of core samples obtained, clip placement confirmation, laterality and anatomic location, and post-procedure imaging. Missing any element increases denial risk, especially prior imaging justification and laterality specification.