Summary & Overview
CPT 19101: Open Incisional Breast Biopsy
CPT code 19101 denotes an open incisional biopsy of a breast lesion, a surgical diagnostic procedure used to obtain tissue for pathology when a portion of a suspicious breast lesion must be sampled. This code is nationally relevant because breast biopsy procedures are essential for cancer diagnosis and directly affect downstream treatment planning, utilization, and surgical care pathways. Payers commonly encountered in coverage and payment discussions include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of what the code represents, the clinical context for using an open incisional approach versus other biopsy techniques, and the typical sites of service where the procedure occurs. The publication presents billing and policy benchmarks, common modifier usage, and payer coverage considerations when available. It also outlines clinical implications for coding accuracy and documentation to support medical necessity. Data not available in the input is noted where applicable. This summary is designed for national audiences including revenue cycle professionals, surgical teams, and policy analysts seeking concise guidance on the clinical and billing context of CPT code 19101.
Billing Code Overview
CPT code 19101 describes an open incisional biopsy of a breast lesion, in which the provider removes a small amount of tissue from a suspicious breast lesion for diagnostic evaluation. The procedure is performed using an open surgical (incisional) approach to obtain representative tissue for pathology.
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Service type: Surgical diagnostic procedure (open/incisional breast biopsy)
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Typical site of service: Ambulatory surgical center or hospital outpatient/inpatient surgical setting, depending on clinical context and facility resources.
Clinical & Coding Specifications
Clinical Context
A 48-year-old woman presents to the breast clinic with a palpable breast lump in the upper outer quadrant identified on self-exam and confirmed on diagnostic mammography and ultrasound. The lesion measures approximately 1.2 cm and image-guided core needle biopsy is non-diagnostic or inconclusive. The surgeon schedules an open incisional breast biopsy to obtain a tissue sample for definitive histopathologic diagnosis. The procedure is performed in an outpatient ambulatory surgery center or hospital outpatient department under local anesthesia with sedation or monitored anesthesia care. The operative workflow includes preoperative localization (if needed), an incision directly over the lesion, removal of a representative tissue sample for pathology, hemostasis, and layered closure. Specimens are labeled and sent with relevant clinical information. Postoperative instructions address wound care, activity restrictions, and return precautions. Typical documentation includes indication, lesion size and location, surgical approach, anesthesia type, specimen description, estimated blood loss, complications (if any), and pathology request form completion.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | Use when billing only the physician's service separate from technical facility charges. |
50 | Bilateral procedure | Use when an incisional biopsy is performed on both breasts during the same operative session. |
51 | Multiple procedures | Use when the biopsy is performed in addition to other distinct surgical procedures in the same session. |
52 | Reduced services | Use when the biopsy is partially reduced or not completed as originally planned. |
53 | Discontinued procedure | Use when the biopsy is started but terminated due to unforeseen circumstances. |
56 | Preoperative assessment only | Use when only the preoperative evaluation related to the biopsy is billed separately. |
59 | Distinct procedural service | Use to indicate a separate and distinct biopsy procedure when performed on a different lesion or site. |
62 | Two surgeons | Use when two surgeons operate together performing distinct portions of the biopsy. |
76* | Repeat procedure by same physician | Use when the same surgeon repeats the biopsy procedure (note: 76 not in provided list; excluded). |
78 | Unplanned return to OR | Use when the patient returns to the operating room for related complications after the initial biopsy. |
79 | Unrelated procedure or service by same physician during postoperative period | Use when an unrelated procedure is performed during the global period. |
52 | Reduced services | Duplicate entry omitted. |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
207Q00000X | General Surgery | General surgeons commonly perform open incisional breast biopsies for diagnostic tissue sampling. |
207SG0100X | Surgical Oncology | Surgical oncologists perform breast biopsies, particularly when cancer is suspected or complex management is anticipated. |
207XR0401X | Breast Surgery | Breast surgery specialists focus on operative management of breast lesions and reconstruction planning. |
208600000X | Obstetrics & Gynecology | Some OB/GYN surgeons with breast training may perform breast biopsies in select practices. |
363L00000X | Pathology (anatomic) | Pathologists do not perform the procedure but are essential for specimen interpretation and reporting. |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
R92.8 | Other abnormal and inconclusive findings on diagnostic imaging of breast | Indicates abnormal imaging requiring tissue diagnosis via incisional biopsy. |
N63 | Unspecified lump in breast | Common presenting symptom prompting diagnostic biopsy to determine benign vs malignant etiology. |
D24.9 | Benign neoplasm of breast, unspecified | Represents fibroadenoma or other benign masses that may be sampled or excised. |
N60.2 | Recurrent mastitis | Inflammatory or infectious processes may require biopsy if a mass or persistent abnormality is present. |
C50.919 | Malignant neoplasm of unspecified site of right female breast | Malignancy suspected or confirmed may lead to diagnostic biopsy for histologic confirmation. |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
19100 | Excision of breast lesion identified by preoperative placement of radiological marker; open, incisional | Performed when a lesion localized by imaging requires excisional biopsy; may be an alternative or complement to 19101 depending on intent (diagnostic vs excisional). |
19120 | Excision of cyst, fibroadenoma, or other benign lesion, open, one or more lesions | Often used when the surgeon plans to excise the entire palpable benign lesion rather than perform a limited incisional biopsy as in 19101. |
19083 | Biopsy, breast, with placement of marker (clip) when performed, percutaneous, needle | Image-guided percutaneous biopsy is a less invasive diagnostic option that may precede or replace an open incisional biopsy. |
76085 | Localization procedure for lesion; preoperative placement of radiological marker, breast | Performed before 19101 when radiologic localization is required to guide the open incision to a nonpalpable lesion. |
99213 | Office or other outpatient visit for evaluation and management, established patient | Common E/M service for preoperative evaluation or postoperative follow-up related to the biopsy. |