2025 CPT code 42400
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Percutaneous needle biopsy of salivary gland.
Modifiers may apply depending on the circumstances of the procedure.For instance, modifier 59 (distinct procedural service) might be used if the biopsy is performed as a separate procedure.Consult your local coding guidelines for a full list of applicable modifiers.
Medical necessity for a salivary gland biopsy is established when there is clinical suspicion of a mass, inflammation, or other abnormality that requires histopathological evaluation.This can include symptoms such as pain, swelling, or palpable masses.Imaging findings that raise suspicion also justify the procedure.Appropriate documentation of symptoms and imaging is needed to support medical necessity.
The physician is responsible for proper patient preparation, anesthesia administration (if necessary), accurate needle insertion into the salivary gland to obtain an adequate tissue sample, proper handling and preservation of the sample in formalin, and sending it to the pathology lab for analysis.The physician should also document the procedure completely and accurately.
In simple words: The doctor takes tissue samples from a salivary gland using a needle.The sample is sent to a lab for testing.
This CPT code describes the procedure involving percutaneous needle biopsy of a salivary gland.The procedure includes prepping and anesthetizing the patient, inserting a large-bore needle into the salivary gland to obtain tissue fragments for biopsy, placing the sample in formalin, and sending it for pathological evaluation.Additional codes may be necessary if imaging guidance is used.
Example 1: A patient presents with a suspicious mass in their parotid gland. The physician performs a percutaneous needle biopsy under local anesthesia, guided by ultrasound. The tissue is sent for pathology, revealing a benign tumor., A patient with recurrent sialadenitis (salivary gland inflammation) undergoes a percutaneous needle biopsy to rule out malignancy.The procedure is performed in the outpatient setting under local anesthesia. Pathology results are negative for malignancy., A patient with a history of head and neck cancer presents with a new lump near their submandibular gland.A percutaneous needle biopsy is done under local anesthesia to assess for recurrence. The pathologist finds evidence of malignant cells.
Complete medical history, physical examination findings, indication for biopsy, imaging studies (if used), operative report detailing the technique, site of biopsy, sample handling and transport, and pathology report.Informed consent should be documented.
** Always refer to the most current CPT manual and payer-specific guidelines for accurate coding and reimbursement.This information is for guidance only and does not constitute medical advice.
- Revenue Code: P6C (MINOR PROCEDURES - OTHER)
- RVU: This information is not available in the provided text.RVUs vary by payer and location. Consult your local fee schedule.
- Global Days: This information is not provided. The global period for surgical procedures varies depending on the specific procedure and payer guidelines.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier may apply, especially in scenarios where the physician only performs the technical aspects of the procedure. Review payer-specific rules regarding TC modifiers.
- Fee Schedule: Historical fee schedule data is not provided. Refer to historical CPT code books or payer-specific fee schedules for this information.
- Specialties:Otolaryngology, Oral and Maxillofacial Surgery
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center