CPT 19125 Reimbursement Benchmarks | OpenPayer

Summary & Overview

CPT 19125: Excision of Breast Lesion with Radiological Marker, Single Lesion

CPT code 19125 is a nationally recognized billing code for the excision of a breast lesion identified by preoperative radiological marker placement. This open surgical procedure is a critical component in the diagnosis and management of breast abnormalities, including both benign and malignant conditions. The code is widely used in hospital outpatient departments and ambulatory surgery centers, reflecting its importance in modern breast surgical oncology.

Major payers such as Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare provide coverage for this procedure, underscoring its clinical and financial relevance across the healthcare landscape. The publication offers a comprehensive overview of payer coverage, clinical indications, and policy benchmarks related to 19125. Readers will gain insight into the procedural context, typical sites of service, and associated billing practices, including common modifiers and related codes. Additionally, the summary addresses the range of ICD-10 diagnoses applicable to this code, highlighting its role in the management of both benign and malignant breast lesions.

This article serves as a resource for understanding the national landscape of breast lesion excision procedures, with a focus on payer policies, clinical context, and coding practices. It is designed for healthcare professionals, administrators, and policy analysts seeking up-to-date information on surgical breast procedures and their reimbursement.

AetnaBlue Cross Blue ShieldCigna HealthMedicareUnitedHealthcareCPT 19125breast surgerysurgical oncologymedical billingprocedure codinghospital outpatientambulatory surgery centerclinical benchmarkspolicy updatesICD-10 diagnoses

CPT Code Overview

CPT code 19125 describes the excision of a breast lesion that has been identified by preoperative placement of a radiological marker. This procedure is performed as an open surgical intervention and is limited to a single lesion. It is commonly utilized in cases where imaging has detected a suspicious area within the breast, and precise localization is required for surgical removal. The service type is classified as Surgical Procedures on the Breast, and the typical site of service includes the surgical suite in either a hospital outpatient setting or an ambulatory surgery center. This code is integral to breast cancer diagnostics and treatment, facilitating targeted excision of lesions for further pathological evaluation.

Clinical & Coding Specifications

Clinical Context

A typical patient scenario involves a woman who presents with a suspicious breast lesion detected during routine mammography. The lesion is not palpable and requires precise localization for surgical excision. Prior to surgery, a radiological marker is placed to identify the lesion's location. The patient is then taken to the surgical suite, either in a hospital outpatient setting or an ambulatory surgery center, where a surgeon performs an open excision of the single breast lesion using the guidance of the preoperative radiological marker. This workflow is commonly used for both benign and malignant breast lesions that are difficult to localize without imaging.

Coding Specifications

Common Modifiers:

LT - Indicates the procedure was performed on the left breast.
RT - Indicates the procedure was performed on the right breast.
59 - Used to denote a distinct procedural service, typically when multiple procedures are performed that are not normally reported together.
51 - Indicates multiple procedures were performed during the same surgical session.

Associated Provider Taxonomies:

Taxonomy Code	Specialty Name

National Reimbursement Benchmarks

Nationally, the mean rate for Medicare is $650.34, while the average commercial benchmark (BUCA) is $669.78. Commercial payers such as UnitedHealth Group and Cigna have notably higher mean rates, at $885.52 and $830.74 respectively, compared to both Medicare and BUCA.

Rate dispersion varies significantly across payers. Medicare shows the tightest range, with a difference of $65.00 between the 75th and 25th percentiles, indicating relatively consistent reimbursement. In contrast, UnitedHealth Group and Cigna exhibit the widest ranges, with $547.00 and $472.00 respectively, reflecting greater variability in commercial rates.

The table and chart below present a detailed breakdown of national benchmarks for CPT code 19125 by payer.

State Benchmarks

State: Alaska1 / 50

Alaska Benchmarks

Alaska exhibits a wide spread in reimbursement rates for CPT code 19125, with the highest payer (Aetna) showing a mean rate of $2,182.10 and the lowest (Medicare) at $632.67. The rate spread, calculated as the difference between the 75th and 25th percentiles, is most pronounced for Blue Cross Blue Shield ($870.99), indicating substantial variability in commercial payer rates. Cigna also demonstrates a notable spread ($748.75), while Aetna's rates are tightly clustered at the upper end, with all percentiles equal.

Compared to national averages, Alaska's commercial payers consistently reimburse at much higher rates, often more than double or triple their national benchmarks. The table and chart below present the full breakdown of payer-specific rates, highlighting the unique reimbursement landscape in Alaska for this procedure.

Key Insights for Alaska

Aetna is the highest paying payer for CPT 19125 in Alaska, with a mean rate of $2,182.10.
Medicare is the lowest paying payer, with a mean rate of $632.67.
All commercial payers in Alaska reimburse at rates significantly above their respective national averages, with Aetna's mean rate over four times higher than its national benchmark.

CPT 19340: Removal of Intact Breast Implant with Internal Capsulotomy

19300-MASTECTOMY-FOR

19300 – Mastectomy for gynecomastia

19120-EXCISION-OF-CYST-FIBROADENOMA-OR-OTHER-BENIGN-OR-MALIGNANT

19120 – Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, one or more lesions

National Reimbursement Benchmarks

The table and chart below present a detailed breakdown of national benchmarks for CPT code 19125 by payer.

National Mean Rates by Payer for CPT 19125

State Benchmarks

State: Alaska1 / 50

Alaska Benchmarks

Mean Reimbursement Rates by Payer in Alaska for CPT 19125

Key Insights for Alaska

Aetna is the highest paying payer for CPT 19125 in Alaska, with a mean rate of $2,182.10.
Medicare is the lowest paying payer, with a mean rate of $632.67.
All commercial payers in Alaska reimburse at rates significantly above their respective national averages, with Aetna's mean rate over four times higher than its national benchmark.

CPT 19340: Removal of Intact Breast Implant with Internal Capsulotomy

19300-MASTECTOMY-FOR

19300 – Mastectomy for gynecomastia

19120-EXCISION-OF-CYST-FIBROADENOMA-OR-OTHER-BENIGN-OR-MALIGNANT

19120 – Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, one or more lesions

207NS0135X	Surgical Oncology
207RG0100X	Gastroenterology
207RG0300X	Vascular Surgery
207RH0003X	Hospice and Palliative Medicine
207RS0010X	Surgery of the Hand

OpenPayer

Summary & Overview

CPT 19125: Excision of Breast Lesion with Radiological Marker, Single Lesion

CPT Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

National Reimbursement Benchmarks

State Benchmarks

Alaska Benchmarks

Key Insights for Alaska

Related Codes

Related Diagnoses

Related CPT Codes

National Reimbursement Benchmarks

State Benchmarks

Alaska Benchmarks

Key Insights for Alaska

Related Codes