Excision breast lesion

CPT 19125 covers the surgical removal of a breast lump or abnormal tissue that can be felt during examination. This is typically done to remove benign masses like fibroadenomas or to obtain tissue for further testing.

Showing rates for

National Average

Base Medicare rate

$562.83

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

6.69

PE RVU (NF)

9.02

MP RVU

1.69

Total RVU

17.4

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

NCCI bundling edits

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Billing tips

Verify place of service accuracy—facility (POS 22/24) vs non-facility (POS 11) determines $106.42 payment difference
Impact: Incorrect POS coding causes automatic adjustment to lower rate; non-facility setting yields 23% higher reimbursement
For multiple lesions in same breast during same session, bill 19125 for first lesion and 19126 for each additional lesion
Impact: Using 19126 for additional lesions prevents denials; billing multiple units of 19125 will be denied or bundled
Document lesion size, location (clock position and distance from nipple), and palpability clearly to differentiate from image-guided procedures
Impact: Lack of palpability documentation may trigger downcoding to lower-paying biopsy codes or denial for medical necessity
When pathology reveals malignancy and re-excision for margins is needed, use modifier 58 for staged procedure within global period
Impact: Modifier 58 allows full payment for planned re-excision; without it, claim will be denied as included in global surgical package
Bundle local anesthesia administration into 19125; do not separately bill anesthesia codes for local infiltration
Impact: Separate billing for local anesthesia will be denied as bundled; conscious sedation (99152-99153) may be separately reportable
Link appropriate ICD-10 diagnosis codes (D24.-, N60.-, R92.8) to establish medical necessity and avoid screening procedure denials
Impact: Screening-related diagnosis codes may result in cost-sharing changes or denials; diagnostic codes support medical necessity

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 19125 in 2025?

The 2025 Medicare national average reimbursement for CPT 19125 is $562.83 in non-facility settings and $456.41 in facility settings. These rates are based on 17.4 total RVUs multiplied by the 2025 conversion factor of 32.3465. Actual payment may vary by geographic locality based on the GPCI adjustment factors for your area.

How do I bill for multiple breast lesion excisions during the same procedure?

Bill CPT 19125 for the first palpable breast lesion excised, then use add-on code 19126 for each additional lesion removed from the same breast during the same operative session. Do not bill multiple units of 19125, as this will result in denial. Each code requires RT or LT modifier to indicate which breast was treated.

What is the difference between CPT 19125 and 19301 for breast lesion excision?

CPT 19125 is for excision of a palpable breast lesion that can be located by physical exam alone, while 19301 is for excision of lesions requiring preoperative placement of localization devices (wire, seed, clip) because they cannot be reliably palpated. If imaging guidance or wire localization is used to identify the lesion location, 19301 is the correct code, which has higher reimbursement.

Can I bill an E/M service on the same day as CPT 19125?

Yes, but only with appropriate documentation and modifiers. Use modifier 57 if the E/M service resulted in the decision for surgery (for major procedures with 90-day global period). Use modifier 25 if a significant, separately identifiable E/M service was provided for an issue unrelated to the lesion excision. The E/M must be clearly documented as distinct from the routine preoperative assessment included in the surgical package.

What RVU value is assigned to CPT code 19125 in 2025?

CPT 19125 has a total RVU of 17.4 for 2025, consisting of 6.69 work RVUs, 9.02 practice expense RVUs (non-facility), 5.73 practice expense RVUs (facility), and 1.69 malpractice RVUs. The facility setting has lower total RVUs (14.11) due to reduced practice expense when performed in hospital or ASC settings.

Does CPT 19125 require prior authorization from Medicare or commercial payers?

Medicare typically does not require prior authorization for CPT 19125 when medically necessary documentation supports excision. However, many commercial payers do require prior authorization, especially for benign lesions. Check specific payer policies as requirements vary. Some payers mandate trial of observation for asymptomatic benign lesions before approving excision.

What diagnosis codes support medical necessity for CPT 19125?

Common supporting diagnosis codes include D24.- (benign neoplasm of breast), N60.- (benign mammary dysplasia including fibroadenoma), N63.- (unspecified lump in breast), R92.8 (abnormal breast imaging findings), and C50.- (malignant neoplasm of breast). Avoid screening codes (Z12.31) as primary diagnosis, as these indicate screening rather than diagnostic procedures. Link the most specific diagnosis to establish medical necessity for excisional approach.