Biopsy of breast open

CPT code 19101 describes an open surgical biopsy of the breast, where a surgeon makes an incision in the breast to remove a tissue sample for examination. This is different from a needle biopsy and requires an operating room or surgical suite.

Showing rates for

National Average

Base Medicare rate

$310.20

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

3.23

PE RVU (NF)

5.56

MP RVU

0.8

Total RVU

9.59

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

NCCI bundling edits

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Billing tips

Verify place of service code matches actual location: POS 22 (outpatient hospital) triggers facility rate ($219.63) while POS 11 (office) triggers non-facility rate ($310.20)
Impact: Incorrect POS code causes $90.57 payment difference and can trigger recoupment audits
Document whether biopsy was incisional (partial removal) or excisional (complete removal of lesion) as this affects whether 19101 or a more extensive code should be used
Impact: Using 19101 for complete lumpectomy may result in $200-400 underpayment; excisional biopsies removing entire mass may qualify for 19120
Always append laterality modifiers (LT/RT) on the claim line; Medicare and most commercial payers require this for breast procedures
Impact: Missing laterality modifiers cause automatic denials in 60-70% of claims, delaying payment 30-45 days
When image guidance (ultrasound, mammography, MRI) is used intraoperatively, bill the appropriate +19281, +19282, or +19283 add-on code separately
Impact: Failing to bill image guidance add-ons results in $150-250 lost revenue per case
For Medicare patients, verify the biopsy meets medical necessity criteria under LCD/NCD guidelines; document failed or contraindicated needle biopsy attempts
Impact: Lack of medical necessity documentation is the #1 cause of denials, affecting 100% of reimbursement ($219.63-$310.20)
Do not bill 19101 with same-session therapeutic procedures on the same lesion (e.g., 19301 mastectomy); the biopsy is considered inherent to the definitive procedure
Unbundling violations trigger automatic denials and potential fraud allegations with penalties up to 3x the claim amount

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Frequently asked questions

What is the difference between CPT 19101 and 19120?

CPT 19101 is for a biopsy where tissue is removed primarily for diagnostic purposes, while 19120 is for excision of a benign breast lesion with therapeutic intent. If the entire lesion is removed with margins during what was planned as a biopsy, 19120 may be more appropriate. The distinction depends on intent, extent of tissue removal, and whether margins were obtained.

How much does Medicare pay for CPT 19101 in 2025?

Medicare pays $310.20 for CPT 19101 when performed in a non-facility setting (office-based surgical suite) and $219.63 when performed in a facility setting (hospital outpatient or ASC) based on the 2025 national average rates. Actual payments vary by geographic locality based on GPCI adjustments.

Can CPT 19101 be billed with an office visit on the same day?

Yes, but only if the E/M service is significant and separately identifiable from the pre-operative assessment for the biopsy. Append modifier 25 to the E/M code and ensure documentation clearly shows the separate nature of the services. The decision-for-surgery discussion alone typically does not qualify as a separately billable E/M.

What modifiers are required for billing CPT 19101?

Laterality modifiers LT (left) or RT (right) are required by Medicare and most commercial payers. Additional modifiers may include 50 for bilateral procedures, 59 for distinct procedural services, or 76 for repeat procedures. Always verify specific payer requirements as modifier policies vary.

Is CPT 19101 bundled with image-guided localization procedures?

No, pre-operative image-guided localization (wire placement) and intraoperative imaging guidance are separately billable. Use appropriate codes such as 19281-19288 for placement of localization devices and +19281-+19283 for intraoperative margin assessment, but verify payer-specific bundling edits as policies vary.

What RVUs are assigned to CPT 19101 in 2025?

CPT 19101 has a total of 9.59 RVUs in 2025: 3.23 work RVUs, 5.56 non-facility practice expense RVUs (2.76 facility PE RVUs), and 0.80 malpractice RVUs. These are multiplied by the conversion factor of 32.3465 to determine Medicare payment rates.

When should I use CPT 19101 instead of a needle biopsy code?

Use 19101 when an open surgical approach is medically necessary, such as when needle biopsy is technically not feasible (lesion location, patient anatomy), previous needle biopsies were non-diagnostic, patient has contraindications to needle biopsy, or when larger tissue volume is required for diagnosis. Documentation must support why the more invasive approach was chosen.