Summary & Overview
CPT 19120: Open Excision of Breast Cyst or Tumor
Headline: CPT 19120: Open Surgical Excision for Breast Lesions — Procedure Overview and Payer Context
Lead: CPT 19120 covers open surgical excision of cysts, fibroadenomas, other benign or malignant breast tumors, aberrant breast tissue, duct lesions, and nipple or areolar lesions (excluding 19300) for one or more lesions. This code is a standard surgical billing code used across breast surgery and surgical oncology practices.
What the code represents and why it matters: CPT 19120 defines a common operative approach to remove discrete breast lesions when excision is clinically indicated. It matters nationally because it guides billing and coverage for procedures performed in operating room settings, affects surgical workflow in both hospital outpatient departments and ambulatory surgery centers, and interacts with pathology and imaging services that follow excision.
Key payers covered: This publication addresses reimbursement and policy context for Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
What readers will learn: The report provides clinical context for use of CPT 19120, comparisons to related breast procedure codes, and typical settings of care. It identifies common payer considerations and coding nuances relevant to billing and claims submission. Where input data is incomplete, the publication notes "Data not available in the input." The summary and metadata aim to support coding clarity and administrative planning for surgical breast procedures performed in outpatient operating rooms and ASCs.
CPT Code Overview
CPT 19120 describes the open surgical excision of a cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), for male or female patients, one or more lesions. This procedure is categorized as Surgical – Breast (Surgical Oncology / General Surgery) and typically takes place in an operating room setting, either in a hospital outpatient department or an ambulatory surgery center.
Clinical & Coding Specifications
Clinical Context
A middle-aged patient presents with a palpable breast mass discovered on self-exam or clinical breast exam. Imaging (diagnostic mammography and/or targeted ultrasound) localizes a discrete lesion suspicious for a benign tumor such as a fibroadenoma, a cyst, or an indeterminate lump. After imaging assessment and possible needle biopsy, the surgical team schedules an operative excision in the operating room (hospital outpatient or ambulatory surgery center) for removal of one or more lesions under general or local anesthesia. The procedure performed is an open excision of the lesion(s) from the breast tissue for definitive diagnosis and treatment, corresponding to 19120. Typical workflow includes preoperative localization as needed, operative excision with specimen labeling and submission to pathology, intraoperative hemostasis and cosmetic closure, and postoperative recovery with discharge instructions.
Coding Specifications
-
Modifiers
-
59— Distinct procedural service: used when separate incisions during the same operative session are made for distinct lesions or when another procedure normally bundled with19120is performed through a separate incision, indicating a separate service. -
76— Repeat procedure by same physician: used when a subsequent incision site is treated in a later portion of the same operative session or when the same procedure is repeated by the same physician on a separate occasion; applies when documentation supports a repeat excision at a separate site. -
Associated provider taxonomies
| Taxonomy Code | Specialty |
|---|---|
207P00000X | Surgery—General |
207XS0106X | Surgical Oncology |
Related Diagnoses
-
N60.29— Fibroadenosis of unspecified breast- Clinical relevance: Represents benign fibrocystic changes that can present as palpable masses or pain prompting excisional biopsy or removal with
19120when symptomatic or indeterminate.
- Clinical relevance: Represents benign fibrocystic changes that can present as palpable masses or pain prompting excisional biopsy or removal with
-
D24.1— Benign neoplasm of right breast- Clinical relevance: A benign tumor in the right breast that may be definitively treated by open excision using
19120when removal is indicated.
- Clinical relevance: A benign tumor in the right breast that may be definitively treated by open excision using
-
D24.2— Benign neoplasm of left breast- Clinical relevance: A benign tumor in the left breast for which
19120covers excision of one or more lesions.
- Clinical relevance: A benign tumor in the left breast for which
-
N63— Unspecified lump in breast- Clinical relevance: A non-specific palpable breast lump often investigated with imaging and biopsy and potentially managed with excisional removal under
19120if indicated.
- Clinical relevance: A non-specific palpable breast lump often investigated with imaging and biopsy and potentially managed with excisional removal under
-
C50.919— Malignant neoplasm of unspecified site of unspecified female breast- Clinical relevance: Malignancy identified or suspected in the breast; while
19120covers excision of benign or malignant tumors, documentation should reflect oncologic intent and coordination with surgical oncology for definitive management.
- Clinical relevance: Malignancy identified or suspected in the breast; while
Related CPT Codes
| CPT Code | Description | Relationship to 19120 |
|---|---|---|
19100 | Biopsy of breast; needle core | A less invasive diagnostic alternative to 19120; often performed prior to or instead of excisional removal when tissue diagnosis is needed. |
19101 | Biopsy of breast, incisional | An alternative open diagnostic approach; may be used when a partial excision for diagnosis is performed rather than complete excision covered by 19120. |
19499 | Unlisted procedure, breast | Used when a performed breast procedure does not match defined codes including 19120; serves as an unlisted alternative when documentation does not align with existing descriptors. |
76095 | Stereotactic localization for breast biopsy, each lesion, radiological supervision and interpretation | Ancillary localization service that may precede 19120 when lesion localization is required for operative excision; commonly used together when preoperative or intraoperative localization is performed. |
National Reimbursement Benchmarks
Medicare's national mean allowed rate of $587.55 sits slightly below BUCA (average commercial) at $603.37, indicating that average commercial reimbursements are modestly higher than Medicare for 19120. The absolute difference between Medicare and BUCA mean rates is $15.82.
Dispersion (P75 − P25) varies across payers: UnitedHealth Group shows the widest spread at $490.81 (P75 $982.33 − P25 $491.52), followed by Cigna at $431.75, indicating more variability in negotiated rates. Aetna has a narrower spread of $266.61 and Medicare is the tightest among these with a spread of $62.00, reflecting relatively consistent allowed amounts. The table and chart below present the full breakdown.
State Benchmarks
State: AK1 / 50
Alaska Benchmarks
Alaska exhibits a notably wide rate spread for CPT code 19120 among commercial payers, with Blue Cross Blue Shield showing a 75th minus 25th percentile difference of $783.70, and Cigna displaying a spread of $680.75. Aetna's rates are tightly clustered, with all percentiles at $2,223.50, indicating little variation. Compared to national averages, Alaska's commercial mean rates are significantly higher, with Aetna's mean rate in Alaska more than four times its national mean. Medicare rates in Alaska are slightly below the national average, but the gap between Medicare and commercial payers is much larger in Alaska than nationally.
The table and chart below present the full breakdown of mean rates and percentile distributions for each payer in Alaska, highlighting the substantial differences in reimbursement levels across payers.
Key Insights for Alaska
- Aetna is the highest paying payer for CPT 19120 in Alaska, with a mean rate of $2,037.48.
- Medicare is the lowest paying payer, with a mean rate of $571.26, significantly below the commercial payers.
- All Alaska commercial payer rates are substantially higher than their respective national averages, with Aetna's mean rate over four times the national mean.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.