$503.47–$558.74
Use 19112 when a breast duct fistula is excised. Nipple exploration is a different procedure when no duct fistula excision is performed.
On this page
CMS RVU26D · Effective 2026-10-01
19112 Breast surgery Medicare reimbursement rates in Pennsylvania
Reports surgical removal of a breast duct fistula, typically for persistent drainage from a fistulous tract involving the nipple or areola. Compare 19112 office and facility rates across CMS payment localities in Pennsylvania.
Amounts below use the non-QP conversion factor for participating physicians. These are base physician payments before claim-level adjustments, not patient costs or total hospital charges.
What does Medicare pay for 19112 in Pennsylvania?
Pennsylvania has 2 payment localities in this comparison. Use the service location to choose the applicable amount. These are the supported base rates for the 2 payment areas shown below, using the same CMS release.
Office / nonfacility
$475.30–$528.70
2 of 2 localities have a supported rate.
Facility setting
$314.93–$346.85
2 of 2 localities have a supported rate.
These are locality ranges, not averages or address-specific quotes. A facility-setting amount covers the physician service; it does not include a hospital’s separate bill. Choose a locality below to inspect its calculation, compare other payment areas, or price a percentage of Medicare.
Breast surgery
About 19112: Breast duct fistula excision
Reports surgical removal of a breast duct fistula, typically for persistent drainage from a fistulous tract involving the nipple or areola.
A surgeon excises a fistulous tract involving a breast duct, commonly to treat persistent drainage near the nipple or areola. The procedure is generally performed in an operating room and is distinct from sampling a breast mass or exploring the nipple without excising a duct fistula. The operative report should establish that the target is a duct fistula and describe its location and excision.
Report this code for definitive excision of the fistula, rather than for a diagnostic breast biopsy or removal of a separate breast lesion. It has a 90-day global period, including the day-before preoperative visit and 90 days of related postoperative care. For multiple procedures in the same session, the highest-valued procedure is paid in full and other procedures are subject to the standard reduction. Bilateral reporting with modifier 50 is paid at 150%. Assistant-at-surgery payment requires documented medical necessity; co-surgeons and team surgery are not permitted.
CMS billing rules for 19112
- Global period
- Major surgery with a 90-day global period: the day-before preoperative visit and 90 days of related postoperative care are included.
- Multiple procedures
- Standard multiple procedure reduction: the highest-valued procedure is paid in full and others at 50% when performed in the same session.
- Bilateral procedures
- Bilateral procedure with modifier 50 is paid at 150%.
- Assistant at surgery
- Assistant at surgery is paid only with documentation of medical necessity.
- Co-surgeons
- Co-surgeons not permitted.
- Team surgery
- Team surgery not permitted.
Where the value comes from
- Work RVU3.71 · 25%
- Practice expense (office) RVU10.42 · 69%
- Malpractice RVU1.01 · 7%
21
Medicare services in 2024 · #5884 by national volume
This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.
19112 compared with similar codes
Office rates for Pennsylvania, from the same CMS release.
$543.27–$599.59
Use 19120 for excision of a breast lesion; use 19112 when the surgical target is a duct fistula.
$330.98–$366.33
19101 is an open breast biopsy for diagnostic tissue sampling. 19112 is therapeutic excision of a duct fistula.
$153.60–$170.60
19100 describes percutaneous breast biopsy. It is not the code for surgical removal of a duct fistula.
Compare 19112 by payment locality
Find the payment area for your service address, then open its rate page for calculation inputs, release history and the percentage-of-Medicare tool. A city may cross payment-area boundaries; the ZIP lookup above helps resolve the location.
2 of 2 payment localities
Metropolitan Philadelphia →
Office / nonfacility
$528.70
Facility
$346.85
Rest Of Pennsylvania →
Office / nonfacility
$475.30
Facility
$314.93
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19112 billing questions
Can this code be used for a breast mass biopsy?
No. This code describes excision of a duct fistula, not diagnostic sampling of a mass. An open or percutaneous biopsy code may apply when the service is tissue sampling.
What documentation supports reporting 19112?
The operative report should identify the duct fistula, its breast location, and the excision performed. Document the side when the procedure is unilateral.
How is bilateral excision reported?
CMS pays bilateral reporting with modifier 50 at 150%. The documentation should support excision of a duct fistula on both sides.
What postoperative care is included?
The 90-day global period includes the day-before preoperative visit and 90 days of related postoperative care.
When is assistant-at-surgery payment allowed?
CMS allows assistant-at-surgery payment only when medical necessity is documented. Co-surgeons and team surgery are not permitted for this code.
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense, and malpractice RVUs, adjusted by each locality’s geographic indices and the applicable conversion factor. Unavailable or separately priced services are labeled rather than assigned a made-up amount.
Source: RVU26D. Effective 2026-10-01 through the day before 2027-01-01.
1,66619101,,Biopsy of breast open,A,,3.15,6.55,,2.54,,0.79,10.49,6.48,0,010,0.10,0.80,0.10,2,1,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
1,66719105,,Cryosurg ablate fa each,A,,3.60,71.34,,1.22,,0.98,75.92,5.80,0,000,0.00,0.00,0.00,2,1,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
1,66819110,,Nipple exploration,A,,4.33,10.54,,5.19,,1.13,16.00,10.65,0,090,0.10,0.71,0.19,2,1,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
1,66919112,,Excise breast duct fistula,A,,3.71,10.42,,5.19,,1.01,15.14,9.91,0,090,0.10,0.71,0.19,2,1,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
1,67019120,,Removal of breast lesion,A,,5.77,9.94,,4.99,,1.45,17.16,12.21,0,090,0.10,0.71,0.19,2,1,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
1,67119125,,Excision breast lesion,A,,6.52,10.81,,5.35,,1.68,19.01,13.55,0,090,0.10,0.71,0.19,2,1,1,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
1,67219126,,Excision addl breast lesion,A,,2.86,0.72,NA,0.72,,0.73,4.31,4.31,0,ZZZ,0.00,0.00,0.00,0,0,1,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00