Bx breast 1st lesion mr imag

CPT 19085 covers an MRI-guided breast biopsy of the first lesion, where a radiologist uses magnetic resonance imaging to precisely locate and sample suspicious breast tissue that may not be visible on mammogram or ultrasound.

Showing rates for

National Average

Base Medicare rate

$711.95

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

3.64

PE RVU (NF)

18.04

MP RVU

0.33

Total RVU

22.01

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

NCCI bundling edits

Loading bundling edits…

Billing tips

Always verify place of service codes carefully - POS 22 (outpatient hospital) yields $171.44 while POS 11 (office) yields $711.95, a $540.51 difference
Impact: $540.51 revenue difference per procedure based solely on place of service designation
Bill 19086 for each additional lesion biopsied in the same breast during the same session; do not repeat 19085
Impact: Additional $400-500 per additional lesion when properly documented and coded
Ensure marker clip placement is documented in the operative note as this is bundled into 19085 and supports medical necessity
Impact: Prevents denials for inadequate documentation and supports potential future excision procedures
Pre-authorization is required by most commercial payers for MRI-guided breast biopsy; obtain prior to scheduling to avoid write-offs
Impact: Prevents 100% claim denial; average commercial reimbursement ranges $1,200-2,500 for non-facility settings
Document why ultrasound or stereotactic biopsy was not suitable (lesion only visible on MRI) to support medical necessity
Impact: Reduces denial rate by 30-40% when payers question why more expensive MRI guidance was necessary
Submit pathology correlation documentation showing concordance between imaging findings and biopsy results to support quality metrics
Impact: Strengthens case for payment and reduces post-payment audit risk, particularly for Medicare and managed care contracts

Common denials

Live Field Datano reports yet

Real billers contribute denial patterns and appeal strategies for this code. Once 5+ reports come in, you’ll see live aggregated data here — the only place this exists, free.

Working with CPT 19085?

Get the free Revenue Protection Toolkit — the denial triggers, modifier pitfalls, and bundling conflicts that quietly cost you reimbursement. Instant download.

Help build the field knowledge

MedPayIQ gets smarter as billers contribute. If you've had this code denied, share what happened so others learn from it. Anonymous, no patient info.

Related actions

Frequently asked questions

What is the Medicare reimbursement rate for CPT 19085 in 2025?

The 2025 Medicare national average reimbursement for CPT 19085 is $711.95 in non-facility settings and $171.44 in facility settings. The significant difference reflects whether the provider owns the equipment and bears the practice expense costs versus performing the procedure in a hospital setting.

Can CPT 19085 be billed bilaterally with modifier 50?

Yes, CPT 19085 can be billed with modifier 50 when MRI-guided biopsies are performed on both breasts during the same session. This typically results in 150% reimbursement of the single procedure rate. Alternatively, some payers prefer RT and LT modifiers on separate line items.

What is the difference between CPT 19085 and 19086?

CPT 19085 is used for MRI-guided biopsy of the first breast lesion, while 19086 is an add-on code for each additional lesion biopsied in the same breast during the same session. Code 19086 cannot be billed alone and must be reported with 19085.

Do I need prior authorization for CPT 19085?

Most commercial insurance plans and Medicare Advantage plans require prior authorization for CPT 19085 due to the high cost and necessity of MRI guidance. Medicare traditional typically does not require prior auth but does require medical necessity documentation. Always verify with the specific payer before scheduling.

What RVU value does CPT 19085 carry in 2025?

CPT 19085 has a total RVU of 22.01 in 2025, consisting of 3.64 work RVU, 18.04 non-facility practice expense RVU (1.33 facility PE RVU), and 0.33 malpractice RVU. The high PE RVU reflects the expensive MRI equipment required.

Can I bill a diagnostic breast MRI and MRI-guided biopsy on the same day?

Yes, but documentation must clearly support that the diagnostic MRI revealed a finding requiring immediate biopsy. Use modifier 59 on the biopsy code to indicate a distinct procedural service. Many payers scrutinize this combination and may deny without clear documentation of medical necessity for same-day biopsy.

Is marker clip placement separately billable with CPT 19085?

No, marker clip placement is included in CPT 19085 and should not be billed separately. The clip placement is considered integral to the biopsy procedure for future localization purposes. Attempting to bill separately (such as with 19281-19288) will result in bundling denials.