Breast Biopsy Procedures (CPB 0269, reviewed 2026-05-14)

By May 14, 2026: Billing team must implement the following changes in the billing system: (1) Configure CPT codes 19081-19086 and 19283-19288 to require documentation of BI-RADS category 4 or 5 findings before claims are submitted to Aetna. (2) Create automated rejection rules for experimental/non-covered codes: 0546T (RadioFrequency spectroscopy/MarginProbe), 0945T (pegulicianine/Lumisight fluorescence), 76376-76377 (3D volumetric imaging), and any claims mentioning magnetic seeds (Magseed), SAVI SCOUT surgical guidance, or tomosynthesis-guided RFID localizer placement. (3) Update claim scrubbing logic to flag any breast biopsy/localization claims (19281-19288) that lack documentation of imaging modality (mammographic, stereotactic, ultrasound, or MR guidance) as BI-RADS indicator. (4) Communicate to providers and radiology partners that digital breast tomosynthesis-guided biopsy is now an acceptable alternative to mammographically-guided biopsy. (5) Update encounter templates and prior authorization forms to prompt for BI-RADS category verification. Providers should submit claims with operative notes documenting lesion characteristics (BI-RADS 4 or 5 status). Failure to include required documentation will result in denials for covered codes; claims for experimental procedures will be denied automatically.