TL;DR: The Centers for Medicare & Medicaid Services modified NCD 272, governing percutaneous image-guided breast biopsy coverage under Medicare, with a policy update recorded January 9, 2026. Here's what billing teams need to know.
This update to the CMS percutaneous image-guided breast biopsy coverage policy confirms and restates the existing national coverage framework under NCD 272 Medicare. The policy covers two distinct clinical scenarios — non-palpable breast lesions and palpable lesions that are difficult to biopsy by hand — with meaningfully different rules for each. The policy does not list specific CPT or HCPCS codes in the current document, so your coding depends on your MAC's guidance and internal charge capture for these procedures.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | Percutaneous Image-Guided Breast Biopsy |
| Policy Code | NCD 272 |
| Change Type | Modified |
| Effective Date | 2026-01-09 |
| Impact Level | Medium |
| Specialties Affected | Radiology, Breast Surgery, Ambulatory Surgical Centers, Inpatient and Outpatient Hospital Facilities |
| Key Action | Confirm your MAC's local criteria for palpable lesions and audit your documentation to match BIRADS grading requirements before submitting claims |
CMS Percutaneous Image-Guided Breast Biopsy Coverage Criteria and Medical Necessity Requirements 2026
NCD 272 is the National Coverage Determination governing Medicare coverage of percutaneous image-guided breast biopsy. The Centers for Medicare & Medicaid Services first set the effective date for coverage at January 1, 2003. The January 9, 2026 modification updates the policy record — billing teams should treat this as a prompt to review documentation practices now.
The coverage policy splits into two buckets. Get them wrong, and you're looking at a claim denial.
Non-palpable lesions are the cleaner case. Medicare covers percutaneous image-guided breast biopsy using stereotactic or ultrasound imaging when the lesion is non-palpable and graded BIRADS III, IV, or V. That means a "probably benign" finding (BIRADS III) clears the bar for coverage — which surprises some billing teams who assume only suspicious or malignant gradings qualify.
BIRADS I and II do not meet medical necessity under this policy. A BIRADS I read is negative. A BIRADS II is a benign finding. Neither supports a covered percutaneous image-guided biopsy under NCD 272. If your clinician documents a BIRADS II and your team bills for this procedure, expect denial.
Palpable lesions are where this gets complicated. Medicare covers percutaneous image-guided biopsy for palpable lesions only when those lesions are difficult to biopsy using palpation alone. The policy explicitly gives Medicare Administrative Contractors — your MAC — the discretion to define what "difficult to biopsy using palpation" means in practice.
That MAC-level discretion is the real issue here. There is no single national standard for what makes a palpable lesion "difficult." Your MAC sets that bar. If you're billing for palpable lesion biopsies and you haven't confirmed your MAC's local guidance, you're billing blind. Pull your MAC's local coverage determination or LCD on this topic before January 9, 2026 if you haven't already.
The benefit categories under this policy are broad. CMS covers these services across ambulatory surgical center facility services, inpatient hospital services, outpatient hospital services incident to a physician's service, and physicians' services. If your facility type isn't on that list, flag it with your compliance officer.
Prior authorization is not explicitly required under this national policy — but that does not mean your MAC hasn't layered on prior auth requirements at the local level. Check your MAC's guidance directly. Assuming no prior authorization is needed without confirming it is exactly the kind of assumption that generates unnecessary denials.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Non-palpable breast lesion, BIRADS III (Probably Benign) | Covered | Not specified in NCD 272 | Stereotactic or ultrasound image guidance required |
| Non-palpable breast lesion, BIRADS IV (Suspicious Abnormality) | Covered | Not specified in NCD 272 | Stereotactic or ultrasound image guidance required |
| Non-palpable breast lesion, BIRADS V (Highly Suggestive of Malignancy) | Covered | Not specified in NCD 272 | Stereotactic or ultrasound image guidance required |
| Non-palpable breast lesion, BIRADS I (Negative) | Not Covered | Not specified in NCD 272 | Does not meet medical necessity under NCD 272 |
| Non-palpable breast lesion, BIRADS II (Benign Finding) | Not Covered | Not specified in NCD 272 | Does not meet medical necessity under NCD 272 |
| Palpable breast lesion, difficult to biopsy by palpation alone | Covered | Not specified in NCD 272 | MAC discretion applies — confirm local criteria with your MAC |
| Palpable breast lesion, not documented as difficult to biopsy | Not Covered | Not specified in NCD 272 | Standard palpation biopsy is the appropriate approach; image guidance not medically necessary |
CMS Percutaneous Image-Guided Breast Biopsy Billing Guidelines and Action Items 2026
The policy mechanics here are not new — coverage has been in place since 2003. What changes on January 9, 2026 is the policy record. Use this as a forcing function to audit your current documentation practices and confirm your MAC's local position.
| # | Action Item |
|---|---|
| 1 | Confirm your MAC's LCD on palpable lesions before January 9, 2026. The policy gives MACs discretion to define "difficult to biopsy using palpation." Your MAC's local coverage determination is the controlling document for that definition. If you don't know what your MAC has published, find it now. Billing palpable lesion biopsies without confirming that local standard is the fastest path to a claim denial. |
| 2 | Audit your documentation for BIRADS grading on every non-palpable lesion claim. The medical necessity standard is explicit: BIRADS III, IV, or V. If the radiologist's report is in the record and it says BIRADS I or II, the claim fails. Train your clinical documentation team to flag these cases before they reach billing. Don't wait for a denial to find the problem. |
| 3 | Do not assume CPT codes from the NCD alone. NCD 272 does not list specific CPT or HCPCS codes. Your percutaneous image-guided breast biopsy billing must map to the correct procedure codes based on the imaging modality used (ultrasound vs. stereotactic) and the specific technique performed. Confirm your charge capture reflects the right codes for each encounter type. If you're unsure which codes apply to your practice's specific workflow, talk to your billing consultant before the effective date. |
| 4 | Verify benefit category alignment for your facility type. This policy covers ASC facility services, inpatient hospital, outpatient hospital incident to a physician's service, and physicians' services. If your facility bills under a different benefit category, confirm with your compliance officer whether NCD 272 applies to your claim type. |
| 5 | Check prior authorization requirements with your MAC directly. NCD 272 does not require prior authorization at the national level. But MACs can — and do — add local requirements. Call or check your MAC's website to confirm whether prior auth is required for these procedures in your jurisdiction. |
| 6 | Review the cross-reference transmittal. CMS cross-references Program Memorandum Transmittal AB-02-128 in this policy. That transmittal contains the original claims processing instructions. If your team hasn't reviewed it, pull it from CMS.gov. It may contain billing guidelines that affect how you submit claims. |
| 7 | Brief your coders on the BIRADS system terminology. The Breast Imaging Reporting and Data System grading scale — from Grade I (negative) through Grade V (highly suggestive of malignant neoplasm) — directly controls medical necessity. Your coders need to understand what each grade means and how it maps to covered vs. non-covered status. A coder who doesn't recognize BIRADS terminology in a radiology report is a claim denial waiting to happen. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Percutaneous Image-Guided Breast Biopsy Under NCD 272
NCD 272 does not list specific CPT, HCPCS, or ICD-10 codes in the current policy document. This is notable — and a real gap for billing teams.
Because no codes are specified in the national policy, your percutaneous image-guided breast biopsy billing depends on:
- Your MAC's local guidance — Check for any LCD or article your MAC has published that maps specific CPT codes to this NCD. MACs sometimes publish billing articles that supply the code-level detail the NCD omits.
- Your internal charge capture protocols — Your charge capture should already map the imaging modality (ultrasound vs. stereotactic) and biopsy technique to the correct procedure codes. If it doesn't, that's the gap to close before January 9, 2026.
- Transmittal AB-02-128 — The claims processing instructions referenced in NCD 272 may contain code-level guidance. Pull that document directly from CMS.gov.
If you're not sure which codes your team should be using for these procedures under Medicare, loop in your billing consultant. This is not a situation where guessing on code selection is acceptable — percutaneous image-guided biopsy procedures carry meaningful reimbursement, and a miscoded claim either leaves money on the table or triggers a denial or audit.
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