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CPT 19120: Open Excision of Suspicious Breast Lesion
CPT code 19120 denotes the open surgical excision of one or more suspicious breast lesions in male or female patients. This widely used operative code captures definitive removal of palpable or radiographically suspicious lesions for diagnostic or therapeutic intent and is a common entry point for further breast pathology and management. Nationally, accurate coding for open excision procedures affects surgical quality reporting, claims adjudication, and downstream oncology workflows.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, United Healthcare, and Medicare. The publication outlines common clinical contexts for use, how 19120 relates to percutaneous biopsy and unlisted breast procedures, and the typical sites of service where the procedure is performed. Readers will find benchmarks for utilization and payment practice (where available), guidance on coding relationships to related procedures such as needle biopsy and stereotactic localization, and a clinical framing to support correct claim submission.
This summary is written for a national audience and highlights procedural scope, payer considerations, and related coding references to assist billing staff, coders, and clinical managers in aligning clinical documentation with claims submission and review processes.
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Billing Code Overview
CPT code 19120 describes the open excision of one or more suspicious breast lesions in a man or woman. This procedure involves a surgical, open approach to remove palpable or clinically/ radiologically suspicious lesions for diagnostic and therapeutic purposes.
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Service type: Surgical excision (open procedure)
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Typical site of service: Hospital operating room or ambulatory surgical center
National Reimbursement Benchmarks
Medicare’s mean rate for CPT 19120 sits at $587.60, while BUCA’s average commercial mean is substantially higher at $1,821.90, indicating commercial payments can be roughly three times Medicare for this code. This gap highlights a common pattern where commercial networks, represented here by BUCA, pay materially above the federal benchmark for this procedure.
Dispersion measured by the interquartile range (P75−P25) varies notably across payers. Blue Cross Blue Shield has the widest IQR at $2,775.00 (P75 $3,771.00 − P25 $965.60), followed by BUCA at $1,792.00 (P75 $2,505.00 − P25 $717.30). UnitedHealth Group and Cigna show similar mid-level spread at $515.00 and $418.90 respectively, while Aetna is the tightest with an IQR of $356.80, suggesting Aetna’s contracted rates are comparatively clustered around its median.