Cheryl Proval

One would be hard-pressed to find a medical indication in the literature for taking a knife to a breast for anything other than a lumpectomy or mastectomy. Why, then, did 60% of the women who received breast biopsies under Medicare in 1999 get surgical biopsies?

That figure represents the newest data from the Centers for Medicare and Medicaid Services. In 1999, Medicare paid for 35,502 core needle biopsies under CPT code 19100, and 54,330 open surgical biopsies under CPT code 19101. That is roughly a 60-40 ratio for surgical vs needle biopsy. But there is more: An additional 59,368 excisions of cysts, fibromas, and other benign masses were performed under CPT code 19120; and 59,775 excisions of breast lesions were performed under CPT code 19125. Presumably, the purpose of many of these procedures was to rule out or diagnose breast cancer, but it is impossible to say how many.

When viewed in comparison to data from 1998, some interesting shifts can be observed. The number of excisions in 1999 was significantly less than in 1998, when Medicare paid for 70,000 excisions of cysts and fibromas under CPT code 19120, and 65,433 excisions of breast lesions under CPT code 19125. However, some of those excisions must have been shifted to surgical biopsies, because the number in 1999 jumped 29% over the 1998 figure of 42,473. The number of needle biopsies reimbursed under CPT code 19100 in 1999 actually dropped 3% from 36,782 in 1998.

I would like to think that the ratio of core needle to surgical biopsy has improved in the past year and a half. But by all reports, surgical biopsy continues to be performed at a steady clip in the biggest of cities and the most sophisticated cancer centers. Elizabeth Finch delves into the clinical and reimbursement issues in an article beginning on page 20. There are many reasons why open surgical biopsies continue to be performed: compensation, ingrained practice patterns, and ignorance are primary. But rest assured that once a surgeon has a distraught woman with a suspicious mammogram in his office, forget about needle biopsy. A case in point: A coworker recently came in with the news that his wife had suspected breast cancer. I gave him the name of a mammographer at a well-known cancer center and someone else gave him the name of a surgeon at the same center. She went to the surgeon and had a surgical biopsy followed by a lumpectomy with a good prognosis.

Radiology needs to educate both surgeons and women on the availability of this less-invasive and less-costly procedure that is as reliable as a surgical biopsy if performed by an experienced radiologist. Surgeons and women should know that an open surgical biopsy can result in ambiguities in future mammograms, already a challenging read. But waiting to educate a woman until she has a suspicious lump is too late. A woman with an over-amped nervous system and fear pulsing through her veins does not want education, she wants salvation.

If volume is sufficient, core needle biopsy can be profitable for a breast center, helping to offset losses many centers incur by providing mammography. And as of January 1, 2001, when Medicare added reimbursement for supplies utilized in vacuum-assisted biopsies, all needle biopsy procedures can be performed profitably, regardless of the type of guidance used. Be it through in-office marketing, the Internet, articles in the local newspaper, and outreach to surgical societies, now is the time to educate the public and surgeons on the benefits of core needle biopsy.

Cheryl Proval

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