Removal of breast lesion

CPT 19120 covers the surgical removal of a breast lump or abnormal tissue through an open procedure. This is typically performed when a suspicious mass is found during imaging or physical exam and needs to be removed for examination or treatment.

Showing rates for

National Average

Base Medicare rate

$510.43

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

5.92

PE RVU (NF)

8.4

MP RVU

1.46

Total RVU

15.78

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

NCCI bundling edits

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Billing tips

Always append laterality modifier (RT or LT) on initial claim submission to avoid automatic denial and reprocessing delays
Impact: Prevents 15-30 day payment delays and reduces administrative rework costs averaging $25-40 per claim resubmission
Verify setting of service carefully - non-facility rate is $510.43 vs facility rate $412.74, a difference of $97.69 per procedure
Impact: Billing in appropriate setting maximizes allowed amount; incorrect POS code may reduce payment by 19% or trigger recoupment
Document lesion size, depth, and margins obtained in operative report - specific measurements support medical necessity and may justify modifier 22 for lesions >5cm
Impact: Strong documentation can support 20-50% payment increase ($82-255 additional) with modifier 22 for complex cases
Do not unbundle 19120 with same-site image guidance codes (76942, 77002) if guidance is integral to lesion localization; use 19125/19126 for image-guided excision instead
Impact: Prevents NCCI edit denials and potential audit flags; inappropriate unbundling can trigger $412-510 recoupment plus potential compliance review
When performing multiple lesion excisions same breast, bill first lesion as 19120 and additional lesions as 19120-59 with clear documentation of separate sites
Impact: Second lesion typically reimburses at 50% ($206-255) when properly documented; failure to use modifier 59 results in bundling denial
Link appropriate ICD-10 codes demonstrating medical necessity (abnormal imaging findings, palpable mass, history codes); avoid screening-only diagnosis codes

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 19120 in 2025?

The 2025 Medicare national average rate for CPT 19120 is $510.43 for non-facility settings and $412.74 for facility settings. The total RVU is 15.78 (Work RVU 5.92, Non-Facility PE RVU 8.4, Facility PE RVU 5.38, MP RVU 1.46) using the 2025 conversion factor of 32.3465.

What is the difference between CPT 19120 and breast biopsy codes?

CPT 19120 is for complete excision of a breast lesion with margins of normal tissue removed, while biopsy codes (19081-19086) involve sampling only a portion of the lesion for diagnosis. 19120 removes the entire abnormality and is both diagnostic and therapeutic, whereas biopsies are primarily diagnostic. You cannot bill both a biopsy and 19120 for the same lesion on the same date of service.

Do I need to use a modifier with CPT 19120?

Yes, laterality modifiers RT (right) or LT (left) are required by Medicare and most commercial payers. Additional modifiers may include 50 for bilateral procedures, 59 for distinct procedural services when billing multiple lesions, 78 for related procedures during the global period, or 22 for unusually complex procedures requiring significantly greater work.

Can I bill CPT 19120 for multiple breast lesions on the same day?

Yes, you can bill 19120 for multiple lesions, but proper documentation and modifiers are essential. Bill the first lesion as 19120-RT or 19120-LT, and additional lesions in the same breast with modifier 59 or 76 to indicate separate sites. For lesions in opposite breasts, use RT and LT modifiers. The second and subsequent lesions typically reimburse at 50% of the primary procedure rate.

What diagnosis codes support medical necessity for CPT 19120?

Appropriate ICD-10 codes include N63.xx (unspecified lump in breast with specific laterality), R92.8 (other abnormal mammogram findings), N60.xx (benign breast dysplasia), D24.x (benign neoplasm of breast), or personal/family history codes combined with abnormal findings. Avoid using only screening codes (Z12.31) without documented abnormality, as this will result in medical necessity denials.

Is CPT 19120 subject to the global surgery period?

Yes, CPT 19120 has a 90-day global surgery period. This means the reimbursement includes preoperative evaluation (usually 1 day before), the procedure itself, and all routine postoperative care for 90 days. Complications requiring return to the OR during this period require modifier 78, and unrelated E/M services need modifier 24.

How do I bill CPT 19120 when wire localization is performed?

When preoperative wire localization is performed, the radiologist bills for the localization procedure (19281-19288) separately. The surgeon bills only 19120 for the excision. Do not bill imaging guidance codes (76942, 77002) with 19120 as they are bundled. If you perform image-guided excision with your own real-time imaging, consider codes 19125 or 19126 instead of 19120.