Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, open, male or female, 1 or more lesions
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Lack of medical necessity - benign lesion without symptoms or concerning features
Very Common19120 (breast lesion excision) denials most often occur when removing asymptomatic benign lesions without clear medical necessity. Insurance requires documented failed conservative management, concerning imaging findings, or patient symptoms justifying surgery over observation.
Common Causes
- • Fibroadenoma <3cm with benign imaging features - observation appropriate
- • Simple breast cyst without recurrence - aspiration more appropriate than excision
- • No documentation of patient symptoms (pain, growth, psychological distress)
Resolution Strategy
Appeal with documentation showing: lesion growth on serial imaging (compare measurements 6-12 months apart), patient symptoms (pain, tenderness interfering with daily activities), psychological distress from palpable mass (document anxiety, impact on quality of life), or concerning features on imaging warranting excisional biopsy (BI-RADS 4). If purely asymptomatic benign lesion with reassuring imaging, observation is standard of care and appeal unlikely to succeed. For cosmetic removal, patient pays out-of-pocket.
2. Pre-authorization not obtained before elective surgery
CommonMost insurance plans require pre-authorization for 19120 (non-emergency breast surgery). Even with clear medical necessity, claim will deny if authorization not secured before scheduling surgery. This is a procedural denial, not a medical necessity denial.
Common Causes
- • Surgery scheduled before insurance approval obtained
- • Authorization request pending when surgery performed
- • Wrong authorization obtained (different procedure or diagnosis code)
Resolution Strategy
Pre-authorization requirement is contractual obligation with insurance. Appeal rarely successful - procedural requirement not waived retroactively. Options: 1) Request retroactive authorization (rarely granted, only for emergent cases), 2) Patient financial hardship appeal, 3) Negotiate reduced self-pay rate with facility. Lesson: always verify insurance requirements and obtain authorization before scheduling elective surgeries. Check authorization status week before surgery to confirm still active.
3. Excision of breast tissue performed - should use partial mastectomy code (19301)
Occasional19120 is for excision of discrete lesions (cyst, fibroadenoma, small tumor). If pathology shows wider excision of breast tissue beyond discrete lesion, or if surgery for cancer treatment, should use 19301 (partial mastectomy) instead. Coding mismatch leads to denial.
Common Causes
- • Oncologic excision with margins - partial mastectomy, not lesion excision
- • Pathology shows breast tissue excised, not just discrete lesion
- • Lumpectomy for cancer coded as 19120 instead of 19301
Resolution Strategy
Review operative report and pathology. If wider breast tissue excision performed (especially for cancer), recode claim with 19301 and resubmit. Include corrected claim form with notation 'Coding error - recoded from 19120 to 19301 based on operative findings.' If truly discrete lesion excision only, appeal with operative report and pathology showing limited excision of defined lesion, not breast tissue reduction. Most successful when corrected code used.
Relative Value Units (RVUs)
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Clinical Information
When to Use
For open excision of breast cyst, fibroadenoma, or other breast tumor
Common Scenarios
Documentation Requirements
- Location and size of lesion(s)
- Method of localization (palpation vs wire/localization)
- Surgical approach and technique
- Number of lesions excised
- Margins and specimen description
Coding Guidelines
Common Modifiers
Bundling Rules
- Includes excision of lesion
- Includes wound closure
- Localization bundled when performed same session
- Frozen section bundled when performed same session
- Multiple lesions excised bundled
Exclusions
- 19301 (partial mastectomy)
- 19303 (simple mastectomy)
- 19125 (excision of breast lesion with wire localization)
Coding Notes
Clinical scenarios
- Location and size of lesion(s)
- Method of localization (palpation vs wire/localization)
- Surgical approach and technique
- Location and size of lesion(s)
- Method of localization (palpation vs wire/localization)
- Surgical approach and technique
- Location and size of lesion(s)
- Method of localization (palpation vs wire/localization)
- Surgical approach and technique
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Code Details
Medicare Pricing
PFSRVU Breakdown
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Ask a QuestionFrequently Asked Questions
CPT 19120 is the billing code for "Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, open, male or female, 1 or more lesions". For open excision of breast cyst, fibroadenoma, or other breast tumor
Medicare pays approximately $510.43 for CPT 19120 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 19120 has a total RVU of 12.25, broken down as: Work RVU 5.50, Practice Expense RVU 6.20, and Malpractice RVU 0.55. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 19120 is "Lack of medical necessity - benign lesion without symptoms or concerning features". 19120 (breast lesion excision) denials most often occur when removing asymptomatic benign lesions without clear medical necessity. Insurance requires documented failed conservative management, concerning imaging findings, or patient symptoms justifying surgery over observation. Common causes include: Fibroadenoma <3cm with benign imaging features - observation appropriate; Simple breast cyst without recurrence - aspiration more appropriate than excision. Appeal success rate is approximately 40-60%.
Key documentation requirements for CPT 19120 include: Location and size of lesion(s); Method of localization (palpation vs wire/localization); Surgical approach and technique; Number of lesions excised. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 19120: Includes excision of lesion. Includes wound closure Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 19120 include: 50 (Bilateral procedure when both sides excised same session), 51 (Multiple procedures performed same session), LT (Left side procedure). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 19120 is 30-50 minutes typical operative time. Time-based codes require documentation of the actual time spent providing the service.