2025 CPT code 21925
(Active) Effective Date: N/A Revision Date: N/A Surgery - Excision Procedures on the Back and Flank Musculoskeletal System Feed
Biopsy of deep soft tissue in the back or flank area.
Modifiers may be applicable depending on the circumstances of the procedure (e.g., 51 for multiple procedures, 76 for a repeat procedure). Consult official CPT guidelines for appropriate modifier usage.
Medical necessity is established by the presence of a suspicious lesion (palpable mass, imaging findings) requiring histological evaluation to guide further management.The biopsy helps determine the nature of the lesion (e.g., benign, malignant) and guides treatment decisions.
The physician or qualified healthcare professional is responsible for performing the biopsy, including making the incision, excising the tissue sample using microdissection techniques if needed, irrigating the wound, and closing the incision with sutures. They are also responsible for sending the specimen for pathological analysis.
In simple words: The doctor removes a small piece of tissue from deep within the back or side area for testing to check for cancer or other problems.They make a small cut, take the sample, and stitch the cut closed.
This CPT code encompasses the excisional biopsy of deep soft tissue located in the back or flank region.The procedure involves an incision through the skin and fascia to obtain a tissue sample for pathological analysis, typically to evaluate for malignancy or other abnormalities. Microdissection may be employed.The wound is irrigated and closed with sutures.
Example 1: A 55-year-old male presents with a palpable mass in his right flank.A biopsy is performed to rule out malignancy., A 72-year-old female has a suspicious lesion detected on imaging in the lower back.An excisional biopsy is undertaken for diagnostic purposes., A 30-year-old male experiences persistent pain in his upper back. An excisional biopsy of deep soft tissue is performed to assess for an underlying cause, such as an infection or inflammatory process.
Preoperative and postoperative diagnoses, indication for biopsy, description of the lesion, location and size of the lesion, surgical technique, specimen handling, pathology report, and any complications encountered during the procedure should all be documented.
** This code is used for excisional biopsies of deep soft tissue. It is important to differentiate this from needle biopsies, which are coded differently (CPT 20206).
- Payment Status: Active
- Specialties:Surgical Oncology, General Surgery
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgery Center