Excise breast duct fistula

CPT 19112 covers the surgical removal of an abnormal connection (fistula) in a breast duct, typically involving excision of the tract and surrounding tissue. This is a definitive surgical repair for chronic or recurrent breast duct fistulas that haven't responded to conservative treatment.

Showing rates for

National Average

Base Medicare rate

$441.85

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

3.81

PE RVU (NF)

8.87

MP RVU

0.98

Total RVU

13.66

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

NCCI bundling edits

Loading bundling edits…

Billing tips

Document setting of service accurately to capture the correct rate: non-facility (office/ASC owned by practice) pays $441.85 vs facility (hospital) pays $320.88
Impact: $120.97 difference per procedure based on place of service code
Clearly document medical necessity including prior treatment failures (antibiotics, I&D procedures, conservative management) to support excision over simpler drainage codes
Impact: Prevents downcoding to 10060/10061 (I&D abscess) which reimburse approximately $100-150 less
Separately document and code any excision of breast mass or tissue sent to pathology if performed beyond the fistula excision itself, as this may support additional codes
Impact: May justify additional codes like 19120 if discrete mass excision performed, adding $400-600
Use modifier 22 for complex cases with operative note documenting unusual circumstances such as multiple fistulous tracts, extensive scar tissue, or significantly prolonged operative time (>50% more than typical)
Impact: Can increase reimbursement by 20-50% ($88-$221 additional) when properly documented and appealed
Always append RT or LT modifier as most payers require laterality specification for breast procedures; failure to do so triggers automatic denials
Impact: Prevents initial denial and 30-60 day payment delay for resubmission
Verify pathology report confirms fistula diagnosis and retain in medical record, as some payers audit for concordance between clinical diagnosis and pathologic findings
Impact: Reduces audit recoupment risk; average recoupment $320-442 per audited claim

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 19112?

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 code 19112 in 2025?

The 2025 Medicare national average payment for CPT 19112 is $441.85 in the non-facility setting (physician office or ASC owned by the practice) and $320.88 in the facility setting (hospital outpatient department). These rates are based on the total RVU of 13.66 and conversion factor of 32.3465. Local rates may vary based on geographic practice cost indices.

What is the difference between CPT 19112 and simple breast abscess drainage codes?

CPT 19112 involves surgical excision of a chronic fistulous tract with removal of the epithelialized tissue, typically requiring layered closure. Simple incision and drainage codes (10060/10061) involve only opening and draining an acute abscess without tissue excision. Code 19112 is appropriate for chronic, recurrent conditions with an established fistula tract, while I&D codes are for acute abscess management.

How many RVUs is CPT code 19112 worth?

CPT 19112 has a total of 13.66 RVUs consisting of 3.81 work RVUs, 8.87 non-facility practice expense RVUs (5.13 facility PE RVUs), and 0.98 malpractice RVUs. The work RVU reflects physician effort and skill, while practice expense RVUs vary significantly based on setting of service.

Can CPT 19112 be billed bilaterally with modifier 50?

Yes, CPT 19112 can be billed with modifier 50 when bilateral breast duct fistulas are excised during the same operative session. Documentation must clearly support medical necessity for bilateral procedures. Most payers reimburse bilateral procedures at 150% of the unilateral allowed amount, though some may require separate line items with RT/LT modifiers instead of modifier 50.

What diagnosis codes are typically used with CPT 19112?

Common ICD-10 codes for 19112 include N61.1 (abscess of breast and nipple), N64.89 (other specified disorders of breast including fistula), and O91.12 or O91.13 (abscess of breast associated with lactation). The specific code depends on whether the condition is infectious, postpartum/lactational, or chronic inflammatory. Documentation must link the diagnosis to the procedure performed.

Does CPT 19112 require prior authorization from insurance?

Prior authorization requirements vary by payer and plan. Many commercial insurers require authorization for outpatient surgical procedures including 19112, particularly when performed in ASC or office settings. Medicare typically does not require prior authorization for 19112, but Medicare Advantage plans may. Always verify with the specific payer before scheduling to avoid denial for lack of authorization.

What is the global period for CPT code 19112?

CPT 19112 has a 90-day global surgical period. This means routine postoperative care for 90 days following the procedure is included in the reimbursement and cannot be billed separately. Any complications, recurrences, or unrelated services during this period require appropriate modifiers (24, 78, 79) to obtain separate payment. Minor procedures performed during the global period are typically bundled unless unrelated.