2025 CPT code 20206
(Active) Effective Date: N/A Revision Date: N/A Surgery - General Excision Procedures Musculoskeletal System Feed
Percutaneous needle biopsy of muscle tissue.
Modifiers may be necessary to indicate additional services or circumstances. Examples include modifiers for multiple procedures (51), repeat procedures (76), and imaging guidance (depending on the specific imaging code utilized).
The procedure is medically necessary when clinical suspicion for a muscle disorder exists, and non-invasive methods have failed to provide a diagnosis.This includes cases of muscle weakness, pain, palpable masses, or abnormal muscle enzyme levels. The biopsy is crucial to differentiate benign conditions from malignant ones and to guide treatment decisions.
The physician or qualified healthcare professional performs the biopsy, including prepping the site, making a small incision, using a needle to obtain a muscle tissue sample, and closing the incision.They may also interpret the results of the pathology report.
In simple words: A small sample of muscle tissue is taken with a needle for testing to help diagnose a medical condition.
This CPT code describes a percutaneous needle biopsy procedure involving the removal of a muscle tissue sample using a needle for diagnostic examination.The procedure typically includes preparing the area, making a small incision, inserting the needle to obtain the tissue sample, and closing the incision.Ultrasound or other imaging guidance may be used and should be reported separately using appropriate codes.The sample is then sent to a laboratory for analysis.
Example 1: A patient presents with unexplained muscle weakness and pain.A percutaneous needle muscle biopsy is performed to evaluate for myopathy or other muscle diseases.The biopsy specimen shows inflammatory changes, consistent with polymyositis., A patient has a palpable mass in their thigh. A percutaneous needle biopsy is performed to determine if the mass is benign or malignant. The pathology report reveals a rhabdomyosarcoma., A patient suffers from recurrent muscle cramps and pain.A percutaneous needle muscle biopsy is ordered to rule out conditions such as muscular dystrophy or metabolic myopathies. The muscle biopsy is unremarkable.
* Detailed history and physical examination documenting the indication for the biopsy.* Preoperative and postoperative notes including assessment of the patient's condition.* Anatomic location of the biopsy site accurately documented.* Procedure note outlining the technique used (including needle size and type) and any complications encountered.* Pathology report with complete microscopic description.* Imaging reports (if applicable, such as ultrasound or CT guidance).
** The size and depth of the biopsy specimen are not explicitly coded in 20206;documentation should clearly specify these details.The code is used for percutaneous needle biopsies of skeletal muscle; biopsies of other soft tissues might require a different code.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:* Pathology* Rheumatology* Neurology* Oncology* Orthopedics
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgery Center