Part B Insider (Multispecialty) Coding Alert

Question: We reported +19295 (Image guided placement, metallic localization clip, percutaneous, during breast biopsy/aspiration [List separately in addition to code for primary procedure]) last week and the claim got rejected, with the EOB saying that only the facility charge (and not the professional charge) would be allowed. Should I appeal this denial?

Texas Subscriber

Answer: No, you needn’t appeal. Code +19295 (Image guided placement, metallic localization clip, percutaneous, during breast biopsy ...) is for placing a clip. However, there is no reimbursement for this code.

How it works: If you look at the relative value unit (RVU) structure for +19295 under the 2013 Medicare Physician Fee Schedule, you will see that there is no monetary value assigned for work (that’s the work of placing the clip), a small amount assigned for practice (that’s the actual cost of the clip), and a tiny amount assigned for malpractice.

When CPT^® created +19295 it decided that the physician work was so minimal with the clip placement that there should be no separate reimbursement for that part of a procedure. Since there is no work reimbursement it doesn’t matter if you report +19295. You will not be paid for your surgeon placing the clip.

Why? When the place of service is 21 (Inpatient hospital) or 22 (Outpatient hospital) or another facility-based location, the physician only receives the work portion of the code. Payers reimburse the facility for the supply.