Prepj tum cav iort prtl mast

CPT code 19294 covers the preparation of the tumor cavity for intraoperative radiation therapy (IORT) during a partial mastectomy (lumpectomy). This involves setting up the surgical site to deliver radiation directly to the tumor bed while the patient is still in the operating room.

Showing rates for

National Average

Base Medicare rate

$159.14

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

PE RVU (NF)

1.16

MP RVU

0.76

Total RVU

4.92

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

NCCI bundling edits

Loading bundling edits…

Billing tips

Always bill 19294 as an add-on code with the primary partial mastectomy code (19301 or 19302); never bill independently
Impact: Standalone billing results in 100% denial; proper sequencing ensures the $159.14 reimbursement is captured
Document the specific IORT device used (e.g., Intrabeam, Xoft) and the medical necessity for immediate radiation in the operative report
Impact: Reduces medical necessity denials by 60-70%; some payers require preauthorization specifically citing the IORT plan
Verify that the primary partial mastectomy code is not bundled with 19294 under NCCI edits; use modifier 59 or XS if required
Impact: Prevents bundling denials; improper modifier use can delay payment by 30-45 days during appeals
Bill same-day radiation oncology codes separately by the radiation oncologist, not the surgeon; coordinate with radiation oncology billing team
Impact: Prevents duplicate billing issues; ensures both professional components are paid without triggering fraud alerts
Confirm patient meets payer-specific criteria for IORT eligibility (age, tumor size, node status) before scheduling
Impact: Preoperative verification prevents denials; Medicare LCD requirements vary by MAC and non-compliance can result in zero payment
Submit with diagnosis codes supporting breast cancer staging (C50.x codes with appropriate laterality) and any relevant Z codes for genetic predisposition
Impact: Proper diagnosis coding supports medical necessity; incomplete staging documentation increases audit selection probability by 40%

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 19294?

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 19294 in 2025?

The 2025 Medicare national average reimbursement for CPT 19294 is $159.14 for both facility and non-facility settings, with a total RVU of 4.92 (Work RVU: 3.00, PE RVU: 1.16, MP RVU: 0.76) using the conversion factor of 32.3465.

Can CPT 19294 be billed alone or does it require another procedure code?

CPT 19294 is an add-on code and cannot be billed independently. It must always be reported with a primary partial mastectomy code (such as 19301 or 19302) and represents the additional work of preparing the tumor cavity specifically for intraoperative radiation therapy.

What modifiers are required when billing CPT code 19294?

A laterality modifier (RT for right breast or LT for left breast) is required for CPT 19294. Depending on payer edits and other procedures performed, you may also need modifier 59 or XS to indicate a distinct procedural service and prevent bundling denials.

Do all insurance companies cover CPT 19294 for intraoperative radiation therapy preparation?

No, coverage varies significantly by payer. While Medicare covers 19294 when medical necessity criteria are met, many commercial payers have restrictive policies or require prior authorization. Some payers still consider IORT investigational for certain patient populations, requiring thorough verification before scheduling.

What documentation is needed to support billing CPT 19294?

Documentation must include the operative report clearly describing tumor cavity preparation for IORT, the specific device/applicator used, medical necessity for immediate radiation, tumor characteristics justifying IORT, coordination with radiation oncology, and total time spent on the preparation beyond the standard partial mastectomy procedure.

How does CPT 19294 differ from the radiation delivery codes?

CPT 19294 covers only the surgeon's work preparing the surgical cavity for radiation delivery during partial mastectomy. The actual radiation planning, physics, and delivery are billed separately by radiation oncology using different CPT codes (77424, 77431, 77432, etc.). These are distinct services by different specialties.

What are the most common reasons for denial of CPT 19294 claims?

The most common denials occur when the code is billed standalone without the primary partial mastectomy procedure, missing laterality modifiers, insufficient documentation of medical necessity or patient selection criteria, bundling issues with the primary breast surgery, and failure to meet payer-specific coverage criteria for IORT candidacy.