02-20-2026
Scenario:
- 01-01-2026 Mammogram: Asymmetric density lower outer quadrant right breast (0.9cm) is mildly suspicious and represents a change from prior mammograms
- 02-01-2026 Breast, right, biopsy: atypical ductal hyperplasia
- 02-20-2026 Right breast localized excisional biopsy-invasive ductal carcinoma, grade 2 of 3
Question: How will you code the 2-20-2026 procedure?
- B210 Excisional breast biopsy
- B215 Excisional breast biopsy, for atypia
Answer: B215 Excisional breast biopsy, for atypia
SEER Appendix C/STORE Appendix A
- B215 Excisional breast biopsy, for atypia
- Note: Use code B215 when patient has biopsy that shows atypical ductal hyperplasia (ADH), an excision is then performed, and pathology shows in situ or invasive cancer. The excisional breast biopsy for ADH diagnosed the cancer, not the core biopsy.
- An excisional breast biopsy removes the entire tumor and/or leaves only microscopic margins.
- This surgical code was added for situations when atypia tissue is excised and found to be reportable.
- Approx. 10-15% of excised atypia are cancer and reportable
