2025 CPT code 21920
(Active) Effective Date: N/A Excision/Biopsy - Surgical Procedures on the Musculoskeletal System Surgery Feed
Biopsy of superficial soft tissue of the back or flank.
Modifiers may be applicable in certain situations. For example, if the procedure is performed on multiple lesions, modifier 51 (Multiple Procedures) may be appended.
Medical necessity for this procedure must be supported by documentation indicating a suspicious lesion requiring further evaluation, such as a change in size, color, or texture, or other concerning symptoms.
The physician or other qualified healthcare professional is responsible for performing the biopsy, including preparing the patient, obtaining the sample, and ensuring proper wound closure. They also decide the biopsy location and depth based on the patient's condition.
In simple words: This procedure involves taking a small tissue sample from just under the skin of your back or flank area. This sample is then sent to a lab to be examined for abnormalities.
This code describes a procedure where a superficial biopsy is taken from the soft tissue of the back or flank.The procedure involves making an incision, obtaining the tissue sample, and closing the incision site.This biopsy targets superficial lesions, meaning they are located close to the skin surface.
Example 1: A patient presents with a palpable, superficial lump on their back. The physician performs a biopsy under local anesthesia to determine the nature of the lump., A suspicious skin lesion is identified on a patient's flank during a routine check-up. A superficial biopsy is performed to rule out malignancy., A patient has a mole on their back that has changed in appearance. A superficial shave biopsy is performed to examine the tissue for cancerous cells.
Documentation should include the location and size of the lesion biopsied, the method of biopsy, and any complications encountered. A pathology report should also be included in the patient's medical record.
** It is important to distinguish between a superficial and deep biopsy when selecting the appropriate code. If the biopsy involves deeper tissues, a different code should be used.
- Specialties:General Surgery, Dermatology, Plastic Surgery
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center