Bx breast add lesion mr imag

CPT 19086 is an add-on code for taking an additional breast tissue sample using MRI imaging guidance during the same session. It's only billed when a second or subsequent lesion is biopsied after the first one.

Showing rates for

National Average

Base Medicare rate

$547.63

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

1.82

PE RVU (NF)

14.95

MP RVU

0.16

Total RVU

16.93

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

NCCI bundling edits

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Billing tips

Always verify the primary code 19085 is billed first with 19086 listed as add-on; 19086 cannot be billed alone
Impact: Standalone billing of 19086 results in automatic denial; proper sequencing ensures $547.63 payment per additional lesion
Document each lesion's distinct location using clock position, depth, and distance from nipple in the operative report
Impact: Specific anatomic documentation supports medical necessity and prevents denials for 'duplicate service'; can protect 100% of add-on reimbursement during audits
Bill in non-facility setting when performed in freestanding imaging center to capture $547.63 vs $85.39 facility rate
Impact: Setting differential of $462.24 per additional lesion (542% higher payment in non-facility)
Use modifier 59 or XU when billing multiple units of 19086 for three or more total lesions to prevent NCCI bundling
Impact: Prevents automatic denial of second and subsequent add-on codes; each properly modified unit reimburses at full rate
Ensure MRI images for each additional lesion are separately stored in PACS with distinct accession or series numbers
Impact: Supports medical necessity during audits; lack of distinct imaging can trigger recoupment of entire $547.63 per lesion
Verify pathology reports confirm distinct specimens for each lesion biopsied; label specimens separately at time of collection
Impact: Pathology documentation of multiple specimens prevents denials for 'unbundling'; missing pathology correlation risks 100% recoupment

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Frequently asked questions

What is the difference between CPT 19085 and 19086?

CPT 19085 is the primary code for MRI-guided biopsy of the first breast lesion, reimbursed at the full procedure rate. CPT 19086 is an add-on code used only for each additional lesion biopsied during the same session, and must always be billed with 19085. The 2025 non-facility rate for 19086 is $547.63 compared to a higher rate for the primary 19085 code.

How many times can I bill CPT 19086 on the same date of service?

You can bill 19086 multiple times based on the number of additional lesions biopsied beyond the first. For example, if three lesions are biopsied, bill 19085 once and 19086 twice. Each additional unit requires distinct documentation of separate lesions and typically requires modifier 59 or XU on the second and subsequent units to prevent denials.

What is the 2025 Medicare reimbursement for CPT 19086?

The 2025 national average Medicare payment for CPT 19086 is $547.63 in the non-facility setting and $85.39 in the facility setting. This represents a significant difference of $462.24, making the place of service critical for reimbursement optimization. The total RVU is 16.93 with a work RVU of 1.82.

Can CPT 19086 be billed alone without 19085?

No, CPT 19086 is an add-on code designated by the plus (+) symbol in CPT and can never be billed as a standalone service. It must always be reported with the primary MRI-guided breast biopsy code 19085. Billing 19086 alone will result in automatic claim denial.

Do I need a modifier when billing multiple units of CPT 19086?

Yes, when billing more than one unit of 19086 (for three or more total lesions), you should append modifier 59 or XU to the second and subsequent units to indicate distinct procedural services. This prevents National Correct Coding Initiative (NCCI) bundling edits and ensures proper payment for each additional lesion.

What documentation is required to support billing CPT 19086?

Required documentation includes: pre-procedure MRI identifying each lesion, operative report with specific anatomic locations for each lesion (clock position, depth, distance from nipple), real-time MRI images of needle placement for each site, separate specimen labeling, post-procedure imaging showing marker placement in each lesion, and pathology reports confirming distinct specimens. Missing any element increases audit and denial risk.

Why is there such a large payment difference between facility and non-facility settings for 19086?

The $462.24 difference ($547.63 non-facility vs $85.39 facility) reflects practice expense RVU variations. In non-facility settings, the provider bears costs for MRI equipment, biopsy supplies, and support staff (14.95 PE RVU). In facility settings, the hospital owns equipment and employs staff, so physician payment covers only professional services (0.66 PE RVU). The facility separately bills a technical component.