General Surgery Coding Alert

Question: Our surgeon excised four distinct breast biopsies from uniquely identified locations requiring separate incisions. We reported 19101 x 4 and got a denial. Did we do something wrong?

Kansas Subscriber

Answer: It sounds like you have adequate documentation to report four units of 19101 (Biopsy of breast; open, incisional) because the surgeon identifies four distinct breast lesions and four separate excisions in the op report.

If Medicare is the payer, your problem might be the Medically Unlikely Edit (MUE) limit of three for 19101. If your surgeon documents distinct procedures at different sites that exceed the MUE limit, as in this case, you can override the MUE.

Best bet: You can use a modifier to override an MUE limit when documentation demonstrates medical necessity for the number of units performed. Because CMS evaluates each claim line against the MUE value, you’ll need to list the same code on separate claim lines with the appropriate modifier.

To override an MUE, Medicare allows modifiers 76 (Repeat procedure by same physician), 77 (Repeat procedure by another physician), or 59 (Distinct procedural service), or anatomic modifiers (such as RT, LT, F1, F2).