When to Report Breast Localization Device Placement with Excisional Breast Procedures in CPT

When reporting codes for percutaneous image-guided placement of breast localization device(s) (19281 -19288) with codes for open breast biopsy (19101), open excision of a breast lesion (19301-19307) or mastectomy (19300-19307) you get the following NCCI edit: Code 1928- is identified as part of another procedure code on the claim (e.g., 19301), coded on the same day. If clinical circumstances justify appending a NCCI-associated modifier to 1928-, payment of both codes may be allowed. All level I and Level II Modifiers are accepted as valid in the OCE. However, only a subset of valid modifiers is used in NCCI editing.

When placement of the localization device and removal of the breast tissue are occurring in the same place, it’s understandable that a coding professional would refrain from reporting a code for placement of the localization device based on the NCCI edit.  However, guidance in the CPT book as well as CPT Assistant indicate reporting of both codes is appropriate.

CPT Guidance

There are multiple places in the CPT codebook that support assignment of a code for placement of a localization device with a code for open biopsy, open excision of breast lesion or mastectomy.

Coding Guidelines

The guidelines for Excision Procedures on the Breast (19081-19126) state the following:

“Open incisional breast biopsy (19101) does not include imaging guidance. However, if an open incisional biopsy is performed after image-guided placement of a localization device, the appropriate image-guided localization device placement code (19281, 19282, 19283, 19284, 19285, 19286, 19287, 19288) may also be reported.”

“Open excision of a breast lesion (eg, lesions of breast duct[s], cyst[s], benign or malignant tumor[s]), without specific attention to adequate surgical margins, with or without the preoperative placement of radiological markers are reported with 19110, 19112, 19120, 19125, 19126. If an open excision of a breast lesion is performed after image-guided placement of a localization device, the appropriate image-guided localization device placement code (19281, 19282, 19283, 19284, 19285, 19286, 19287, 19288) may also be reported.”

The guidelines for Introduction Procedures on the Breast (19281-19298) state the following:

“When an open breast biopsy or open excision of a breast lesion is performed after image-guided percutaneous placement of a localization device, the appropriate image-guided localization device placement code (19281, 19282, 19283, 19284, 19285, 19286, 19287, 19288) may also be reported.”

Parenthetical Instructional Notes

Code 19101 has a parenthetical instructional note that says,

“(For placement of percutaneous localization clip with imaging guidance, see 19281-19288)”

Codes 19281-19288 (Introduction Procedures on the Breast) have a parenthetical instructional note that says,

“To report image-guided placement of breast localization devices without image-guided biopsy, see 19281-19288)”

Codes 19300-19307 (Mastectomy Procedures) have a parenthetical instructional note that says,

“(Intraoperative placement of clip[s] is not separately reported)”

CPT Assistant

CPT Assistant makes the following points in relation to coding for placement of breast localization clips and mastectomy procedures.

• "Intraoperative" refers to the "skin-to-skin" work of an operative procedure. It does not include pre- or post-service work, which may include separately reportable procedures or services.
• Surgeons performing image-guided percutaneous placement of a breast localization device prior to starting an open mastectomy procedure, either in another suite, in the preoperative holding area, or in the operating room would report code a code from the range of 19281-19288.
• The intent of the parenthetical note of "(Intraoperative placement of clip[s] is not separately reported)" associated with the mastectomy codes is to prevent separate reporting of the minimal work involved in intraoperative placement of a device in an open mastectomy wound or cavity for purposes such as marking the margins of the excision for future operations or services (eg, radiation therapy).
• The qualifying factor for reporting placement of a breast localization device is that the device is not placed intraoperatively (ie, during the skin-to-skin portion of a mastectomy procedure).

In Summary

If the provider percutaneously places the localization device prior to performing an open breast biopsy, open excision of breast lesion or mastectomy you DO report both codes. 

If the provider performs an open breast biopsy, open excision of a breast lesion or mastectomy and then places the localization device in the already open site of the procedure, you DO NOT report a code for placement of the localization device. Only the code for the open biopsy, open excision or mastectomy would be reported.

Proper Use of Modifiers

For cases meeting the criteria for reporting both a code for placement of the localization device and a code for an open breast biopsy/excision of breast lesion or mastectomy a modifier will be required to override the NCCI edit. The appropriate CPT modifier for this situation is -59 Distinct Procedural Service. Modifier XE Separate Encounter is used for Medicare beneficiaries or for carriers requiring use of the Medicare modifiers. The modifier will be appended to the code for placement of the localization device.

Final Reminder

Remember, if you are choosing not to assign codes based on an NCCI edit, be sure to review pertinent guidance and check your references to see if there is any applicable coding advice that directs otherwise, as there are times when reporting the code and appending a modifier 59 or X- is appropriate.

Key Takeaways

• Multiple guidelines and instructional notes and official coding advice support reporting placement of a breast localization device in conjunction with excisional breast procedures
• Placement of a localization device prior to performance of an excisional breast procedure rather than intraoperative placement is the factor that determines reportability
• Modifiers -59 or XE (Payer dependent) are appended to the code for placement of breast localization device
• Check for pertinent coding advice and appropriateness of using modifiers before automatically discounting a code included in an NCCI edit. 

Please visit the following HIA resources for additional instruction in CPT coding for breast procedures.

References

• CPT Codebook
• CPT Assistant, May 2021, Volume 31, Issue 5, page 11

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The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.