Summary & Overview
CPT 19100: Breast Core Needle Biopsy for Tissue Diagnosis
CPT code 19100 represents a percutaneous core needle biopsy of a breast lesion used to obtain tissue for histopathologic diagnosis, often to evaluate for breast cancer. This procedure is a common diagnostic step in the evaluation of suspicious breast masses and has national relevance for cancer detection pathways, quality metrics, and care coordination between radiology, surgery, and pathology.
Key payers included in this overview are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the clinical context for 19100, typical sites of service, and payer relevance. The publication outlines what stakeholders can expect to learn about payment benchmarks, coding and billing considerations, and policy updates affecting coverage and utilization for breast core needle biopsy.
The content is aimed at clinicians, billing professionals, and policy analysts seeking a clear reference on the intent and clinical use of CPT code 19100, how it fits into diagnostic workflows for suspected breast cancer, and the payer landscape that commonly reimburses this service. Data not provided in the input, such as associated taxonomies, specific ICD-10 diagnoses, and related codes, are noted as unavailable elsewhere in the document.
Billing Code Overview
CPT code 19100 describes the percutaneous core needle biopsy of a breast lesion. This procedure involves removal of a core tissue sample from a suspicious breast lesion to establish a diagnosis, commonly to evaluate for malignancy such as breast cancer.
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Service type: Image- or palpation-guided diagnostic tissue sampling (core needle biopsy)
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Typical site of service: Outpatient ambulatory surgery center or hospital outpatient department, and may also be performed in office-based procedural settings when appropriate
Clinical & Coding Specifications
Clinical Context
A 48-year-old woman presents to the breast clinic after routine screening mammography identified a 1.5 cm suspicious mass in the upper outer quadrant of the right breast. Targeted diagnostic imaging (diagnostic mammogram and ultrasound) confirms a discrete lesion with suspicious features. The patient is scheduled for a percutaneous core needle biopsy to obtain tissue for histopathologic diagnosis.
The clinical workflow: the patient registers at an outpatient imaging or breast center (typical site of service: outpatient imaging center or ambulatory surgical center). Pre-procedure consent and history are obtained by the ordering provider or breast surgeon. Ultrasound or stereotactic guidance is used by the radiologist or breast surgeon to localize the lesion. Local anesthesia is administered, and multiple core tissue samples are obtained using a core biopsy device. Specimens are handled according to pathology protocols and sent to the laboratory for histologic and immunohistochemical analysis. Post-procedure monitoring occurs in the recovery area; discharge instructions include wound care and signs of complications. The biopsy result guides further management such as surgical excision, systemic therapy, or surveillance.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | When billing only the physician/radiologist professional interpretation separate from technical component |