Excision addl breast lesion

CPT 19126 covers the surgical removal of each additional breast lesion beyond the first one during the same operative session. This is an add-on code used when a surgeon removes multiple breast lumps or abnormal tissue areas.

Showing rates for

National Average

Base Medicare rate

$154.62

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

2.93

PE RVU (NF)

1.13

MP RVU

0.72

Total RVU

4.78

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

NCCI bundling edits

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Billing tips

Bill 19126 only with primary excision codes (19120, 19125) - never as standalone
Impact: Prevents 100% denial; 19126 is an add-on code and will be rejected without appropriate primary code
Report one unit of 19126 for each additional lesion beyond the first, supported by distinct pathology specimens
Impact: Each properly documented additional lesion yields $154.62; undercoding loses revenue on multi-lesion cases
Ensure operative report clearly documents separate incisions or distinct anatomic locations for each lesion
Impact: Prevents medical necessity denials and supports payment for multiple units; vague documentation risks 50-100% recoupment
Verify each lesion has separate pathology specimen labeling and analysis in pathology report
Impact: Auditors require distinct pathology documentation; missing this risks denial of all units beyond the first ($154.62 per unit lost)
Apply RT/LT modifiers when billing multiple units from different breasts to prevent bilateral procedure confusion
Impact: Improves first-pass claim acceptance rate by 15-20% and reduces payer inquiries
Do not append modifier 51 to 19126 as it is modifier 51 exempt per CPT guidelines
Impact: Incorrect modifier 51 usage may trigger automatic payment reduction of 50% by payer systems

Common denials

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 19126 in 2025?

The 2025 Medicare national average reimbursement for CPT 19126 is $154.62 for both facility and non-facility settings. This rate is based on 4.78 total RVUs (2.93 work RVU, 1.13 PE RVU, 0.72 MP RVU) multiplied by the 2025 conversion factor of 32.3465.

Can CPT 19126 be billed alone without another code?

No, CPT 19126 is an add-on code that must be billed with a primary breast excision code such as 19120 or 19125. Billing 19126 alone will result in automatic denial as it cannot stand independently.

How many times can I bill CPT 19126 on the same date of service?

You can bill CPT 19126 for each additional lesion excised beyond the first, with no absolute limit. However, you must document each lesion separately with distinct anatomic locations and individual pathology specimens. Most payers scrutinize claims with more than 3-4 units for medical necessity.

What modifiers should be used with CPT 19126?

Common modifiers include RT/LT for laterality specification, 50 for bilateral procedures, and 59/XS for distinct procedural services. Do not use modifier 51 as 19126 is modifier 51 exempt. Modifier choice depends on the specific clinical scenario and payer requirements.

What is the difference between CPT 19120, 19125, and 19126?

CPT 19120 is for excision of a single breast lesion, 19125 is for excision with preoperative placement of localization device, and 19126 is an add-on code for each additional lesion beyond the first. Use 19126 only in combination with 19120 or 19125.

What documentation is required to bill multiple units of CPT 19126?

Required documentation includes operative report detailing each lesion's location and excision, separate pathology specimen labels for each lesion, pre-operative imaging showing multiple lesions, and clear medical necessity justification. Each additional lesion must be documented as anatomically distinct.

Does CPT 19126 require separate incisions for each lesion?

Not necessarily separate incisions, but documentation must clearly show each lesion is distinct and separate. Multiple lesions can be accessed through the same incision if they are in proximity, but the operative report must specify individual identification, isolation, and excision of each lesion with unique anatomic locations.