CPT code 19125 is for the excision of a breast lesion, a surgical procedure to remove abnormal tissue from the breast.
CPT code 19125 is used to describe the surgical procedure of excising, or removing, a lesion from the breast. This code specifically refers to the removal of a breast lesion that does not require a mastectomy. The procedure involves making an incision in the breast tissue to access and remove the abnormal growth, which is then typically sent to a lab for further analysis. This code is essential for accurate billing and documentation in the healthcare revenue cycle, ensuring that the provider is reimbursed appropriately for the surgical service performed.
When billing for CPT code 19125, various modifiers may be required to provide additional information about the procedure performed. Below is a list of potential modifiers that could be used with CPT code 19125, along with the reasons for their use:
1. Modifier -50 (Bilateral Procedure)
- Used when the procedure is performed on both breasts during the same operative session.
2. Modifier -51 (Multiple Procedures)
- Applied when multiple procedures are performed during the same surgical session.
3. Modifier -52 (Reduced Services)
- Used when the procedure is partially reduced or eliminated at the physician's discretion.
4. Modifier -53 (Discontinued Procedure)
- Applied when the procedure is discontinued due to extenuating circumstances or those that threaten the well-being of the patient.
5. Modifier -59 (Distinct Procedural Service)
- Used to indicate that a procedure or service was distinct or independent from other services performed on the same day.
6. Modifier -62 (Two Surgeons)
- Applied when two surgeons work together as primary surgeons performing distinct parts of the procedure.
7. Modifier -76 (Repeat Procedure by Same Physician)
- Used when the same procedure is repeated by the same physician on the same day.
8. Modifier -77 (Repeat Procedure by Another Physician)
- Applied when the same procedure is repeated by a different physician on the same day.
9. Modifier -78 (Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period)
- Used when a related procedure is performed during the postoperative period of the initial procedure.
10. Modifier -79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period)
- Applied when an unrelated procedure is performed by the same physician during the postoperative period of the initial procedure.
11. Modifier -LT (Left Side)
- Used to specify that the procedure was performed on the left breast.
12. Modifier -RT (Right Side)
- Used to specify that the procedure was performed on the right breast.
Each of these modifiers provides specific information that can affect the billing and reimbursement process, ensuring that the claim accurately reflects the services provided.
When determining if CPT code 19125 is reimbursed by Medicare, it is essential to consult the Medicare Physician Fee Schedule (MPFS) and the guidelines provided by the Medicare Administrative Contractor (MAC) for your specific region. The MPFS is a comprehensive listing of the maximum fees Medicare will pay for various services, and it is updated annually.
To verify if CPT code 19125 is reimbursed, you should:
1. Check the MPFS: Access the latest MPFS to see if CPT code 19125 is listed and to review the associated reimbursement rates. The MPFS will provide detailed information on whether this code is covered and the amount Medicare will reimburse for it.
2. Consult Your MAC: Each MAC may have specific guidelines and policies regarding the reimbursement of certain CPT codes. Contact your regional MAC or visit their website to confirm if CPT code 19125 is reimbursed and to understand any additional documentation or criteria that may be required.
By following these steps, you can determine if CPT code 19125 is reimbursed by Medicare and ensure compliance with all necessary guidelines.
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