Bx breast percut w/o image

CPT 19100 covers a breast biopsy performed through the skin using a needle without image guidance like ultrasound or mammography. The physician uses physical examination and palpation to locate and sample the abnormal breast tissue.

Showing rates for

National Average

Base Medicare rate

$141.68

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

1.27

PE RVU (NF)

2.82

MP RVU

0.29

Total RVU

4.38

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

NCCI bundling edits

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Billing tips

Verify site of service before scheduling—performing in office setting yields 113% higher reimbursement ($141.68 vs $66.31)
Impact: $75.37 additional revenue per procedure in non-facility setting; annualized over 100 procedures equals $7,537 additional revenue
Document explicitly that imaging guidance was NOT used and why the lesion was suitable for palpation-guided biopsy
Impact: Prevents automatic denials and requests for medical records; reduces appeals workload by approximately 30% for this code
Always append laterality modifier (LT or RT) on initial claim submission—this is a mandatory requirement
Impact: Prevents automatic rejection and 14-21 day payment delay; missing laterality accounts for 45% of initial denials for breast procedures
If lesion requires any imaging for localization (even brief ultrasound confirmation), bill 19103 instead of 19100
Impact: 19103 reimburses at $183.77 non-facility (29% higher than 19100); billing 19100 when imaging was used invites fraud allegations
When billing multiple units for separate lesions, create detailed operative report with diagram showing distinct anatomic locations
Impact: Increases approval rate for multiple units from approximately 60% to 85%; supports modifier 59 medical necessity
Do not bill separately for pathology interpretation (88305 or 88307)—specimen handling is included in the surgical pathologist's scope
Impact: Prevents unbundling denials and potential compliance issues; performing physician should only bill 19100, not pathology codes

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Frequently asked questions

What is the difference between CPT 19100 and 19103?

CPT 19100 is for breast biopsy without any imaging guidance (palpation only), while 19103 includes ultrasound, mammographic, or MRI guidance. If any imaging is used to locate or guide the biopsy needle, 19103 is the correct code. The reimbursement difference is significant: 19100 pays $141.68 vs 19103 at $183.77 in non-facility settings.

How much does Medicare pay for CPT code 19100 in 2025?

Medicare pays $141.68 for CPT 19100 in non-facility settings (physician office) and $66.31 in facility settings (hospital outpatient department) based on the 2025 national average rates. Actual payment may vary by geographic locality based on the GPCI adjustments for your area.

Can you bill an E/M visit and 19100 on the same day?

Yes, but only if the E/M service is separately identifiable and significant beyond the typical pre-procedure assessment. You must append modifier 25 to the E/M code and document a distinct evaluation (such as addressing an unrelated problem or comprehensive initial consultation). The biopsy decision alone does not justify a separate E/M service.

Do I need a laterality modifier for CPT 19100?

Yes, laterality modifiers LT (left) or RT (right) are mandatory for CPT 19100. Claims submitted without laterality modifiers will be automatically rejected or denied by Medicare and most commercial payers. This is a common cause of payment delays.

Can you bill CPT 19100 twice for biopsies of both breasts?

Yes, if separate palpable lesions in both breasts are biopsied during the same session, you can bill 19100 twice with RT and LT modifiers on separate line items, or once with modifier 50 for bilateral procedure. Documentation must support distinct lesions requiring separate biopsies. Most payers prefer the RT/LT approach on separate lines.

What RVU value does CPT 19100 have in 2025?

CPT 19100 has a total RVU of 4.38 in 2025, consisting of 1.27 work RVU, 2.82 non-facility practice expense RVU (0.49 facility PE RVU), and 0.29 malpractice RVU. The conversion factor is 32.3465, which when multiplied by total non-facility RVUs equals the $141.68 payment rate.

When is CPT 19100 appropriate versus image-guided breast biopsy codes?

CPT 19100 is appropriate only for clearly palpable, discrete breast masses that can be reliably accessed by physical examination alone without imaging guidance. If there is any uncertainty about lesion location, the lesion is deep or difficult to palpate, or if imaging is used even briefly to confirm needle placement, image-guided biopsy codes (19081, 19082, 19083, or 19103) should be used instead.