On Dec. 9, 2014, the American Medical Association (AMA) published a revised version of the “Errata and Technical Corrections in CPT®2015”1 and provided new instructions for reporting bilateral breast biopsies. This instruction is not in the published 2015 CPT manual due to late implementation; however, it went into effect on Nov. 11, 2014.
The updated instructions clarify that the breast biopsy procedures using imaging guidance should not be reported with a bilateral modifier (i.e., 50, RT/LT) when more than one breast biopsy is performed using the same imaging modality.2 The first procedure should be reported with the applicable primary custom procedural terminology (CPT) 19081, 19083, or 19085. The contra-lateral and/or each additional breast image guided biopsy should be reported with the appropriate add-on code 19082, 19084, or 19086.3
The instruction to report an additional primary code if additional biopsies are performed using different imaging modalities still applies.
A parenthetical instructional note has been revised to indicate that modifier 50 is reported when performing bilateral breast procedures without image guidance, i.e., codes 19100-19120.4