A breast biopsy is the removal of breast tissue or fluid to rule out a malignancy. Tissue or fluid is obtained from the breast for biopsy by either an open surgical (incisional or excisional) or needle technique. The method utilized depends on a number of factors which include:
- Whether or not an abnormality can be felt or only seen with imaging
- How suspicious the abnormality appears on X-ray
- How the breast feels on palpation
- The size, shape, and other distinct characteristics of the abnormality
- The location of the abnormality in the breast and/or its relationship to other anatomic structures
- The number of abnormalities detected during physical examination or with X-ray imaging
- The patient’s medical history and current medications
- The preference of the patient (if an option is medically pertinent).
Breast tissue is inherently nodular and variable, depending on the individual and the phase of the individual’s menstrual cycle. Palpating the breast for lumps is part of the physical breast examination. During breast examination palpable masses may be felt. Non-palpable masses can be seen on a mammogram but cannot be felt. However, all palpable or non-palpable masses should be carefully assessed.
Options in biopsy of the breast
Surgical biopsies can either be excisional or incisional. An excisional biopsy removes the entire lump or suspicious area, while an incisional biopsy removes only a portion of the tumor for the pathologist to examine. Needle biopsies can be performed with either a fine needle for the removal of fluid and tissue or a cutting needle large enough to remove a small nugget of tissue.
Many biopsy methods may rely on image guidance to help precisely locate the lesion or abnomality within the breast. Imaging of the breast may be necessary when a lesion or abnormality is only detected on imaging studies such as a mammography or ultrasound and cannot be felt during examination. Biopsy methods that may require image guidance include:
- Fine needle aspiration biopsy (FNA) (10022)
- Core needle biopsy (19102)
- Vacuum-assisted biopsy (brand name, Mammotome or MIBB) (19103)
- Large core biopsy (19102)
- Open surgical biopsy (excisional or incisional) (19101, 19120)
Fine needle aspiration, core needle, and vacuum-assisted biopsies are performed as percutaneous procedures. Because percutaneous biopsies provide only tissue samples and not the entire lesion, occasionally, additional procedures may be required for final diagnosing and treatment of a breast abnormality.
Imaging the breast through mammography and ultrasound assistance
Early detection of breast abnormalities is made possible through mammography, which is a specific type of imaging that uses a low-dose X-ray system and high contrast high-resolution film, for breast examination.
One of the most recent advances in mammography is digital mammography. With digital mammography, the breast image is captured under a special electronic X-ray detector that converts the image into a digital picture for review on a computer monitor.
Advances in imaging now offer alternatives for the detection and diagnosing of breast cancer. While open surgical biopsies are still commonly performed, image-guided needle biopsies are preferable under many circumstances.
In an image-guided biopsy, a tissue sample for microscopic examination is obtained by passing a hollow needle through the skin into the suspicious lesion.
Evaluation of suspicious breast abnormalities can be performed by an ultrasound-guided breast biopsy. The ultrasound-guided biopsy prevents the need to remove tissue surgically, and also eliminates the radiation exposure that comes from using X-ray to locate a mass.
For ultrasound guidance, the ultrasound probe is placed over the site of the abnormality and using local anesthesia, the radiologist guides a biopsy needle directly into the mass. An automatic spring-loaded device, or the Mammotome, is used to take tissue specimens. Code 76942, Ultrasonic guidance for needle, biopsy, radiological supervision and interpretation, would be reported for the ultrasonic guidance.
The stereotactic localization of a breast mass or abnormality may be used as a substitute for mammographic or ultrasound needle localization.
Stereotactic localization utilizes multiple plane radiologic imaging for needle insertion in a breast lesion that is otherwise located only by an open surgical procedure. The use of stereotactic localization of the breast for biopsy is not indicated for all breast lesions. This technology is commonly necessary for those lesions that are non-palpable. See Coding Clinic for HCPCS, First Quarter 2002, page 3, for additional information on mammography reporting.
Coding and reporting image-guided breast biopsies
The Centers for Medicare & Medicaid Services (CMS) recently published instructions for coding and reporting percutaneous image-guided breast biopsies in program memorandum (PM) AB-02-128.
According to the PM, Medicare covers services provided for percutaneous image-guided breast biopsies. The image guided systems may be either ultrasound or stereotactic. Coverage is provided for a radiographic nonpalpable abnormality that is graded based on the Breast Imaging Reporting and Data System (BIRADS) as probably benign, a suspicious abnormality, or an abnormality. Medicare will also cover palpable lesions that are difficult to biopsy using palpation alone.
The applicable CPT codes listed in this PM for facility reporting are:
- 19102, percutaneous needle core, using imaging guidance
- 19103, percutaneous automated vacuum assisted or rotating biopsy device, using imaging guidance
- 10022, fine needle aspiration; with imaging guidance
Let’s take a look at a few questions
This patient was recently found to have a right breast mass in the upper outer quadrant. She was scheduled to undergo a stereotactic core needle biopsy of the mass. There is no previous history of carcinoma. Stereotactic localization guidance was used, and biopsies of the mass were taken. What are the appropriate codes this encounter?
Report code 19102-RT, Biopsy of breast; percutaneous, needle core, using imaging guidance, and code 76095, Stereotactic localization guidance for breast biopsy or needle placement (e.g. for wire localization or for injection), each lesion, radiological supervision and interpretation, for the breast biopsy performed by stereotactic localization.
This 27-year old patient was seen in our facility a week ago with a history of swelling and tenderness in her left breast. On physical examination, two palpable masses were identified. The patient is now scheduled to undergo a needle biopsy of the left breast. Biopsies were taken from both masses and the tissue samples were sent to pathology. What would the correct code assignment(s) be for this case?
Report code 19100-LT, Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure), and code 19100-LT-59, Biopsy of the breast; percutaneous, needle core, not using imaging guidance (separate procedure), for the procedure performed. Modifier -59 is appended to the second code to indicate the biopsy of more than one lesion performed in the same breast.
A 23-year-old patient was seen with a complaint of breast pain. On further evaluation, a hard nodule was noted in the lower-inner quadrant of the left breast.
The physician scheduled the patient to undergo a fine needle aspiration under ultrasound guidance. The procedure was performed and the patient was discharged home with instructions to follow-up within seven days. What would be the appropriate code assignments?
This patient was seen at our facility three weeks previously for a diagnostic mammogram. The physician documented a right breast mass, probable carcinoma. She is now scheduled to undergo an excisional biopsy of the mass. Through an elliptical incision, the entire mass was excised. The specimen was forwarded to pathology. The patient was transferred to the recovery room in stable condition. What are the correct code assignments for this case?
Report code 19120-RT, Excision of cyst, fibroadenoma, or other benign or malignant, tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19140), open, male or female, one or more lesions, for the excisional biopsy of the breast mass.