2025 CPT code 20251
Effective Date: N/A Surgery - Musculoskeletal System Feed
Open biopsy of a vertebral body in the lumbar or cervical spine.
Modifiers may be applicable in certain circumstances, such as for increased procedural services (22), multiple procedures (51), or distinct procedural service (59).
Medical necessity for this procedure must be established based on clinical findings, imaging studies, and other diagnostic tests suggestive of a condition requiring a tissue diagnosis.The medical record should document the rationale for choosing an open biopsy over less invasive techniques.
The physician prepares the patient, administers anesthesia, positions the patient prone, makes the incision, accesses the vertebral body, obtains the tissue sample, repositions the soft tissues, and closes the surgical incision. The physician may use radiological imaging to locate the lesion.
In simple words: This procedure takes a small piece of bone from your spine for testing. The doctor makes a cut in your lower back or neck, reaches the bone, removes a sample and closes the cut. It helps doctors diagnose conditions such as cancer or infection.
Surgical procedure to obtain a tissue sample from a vertebral body in the lumbar or cervical spine for diagnostic purposes, typically to evaluate a suspected lesion for malignancy or infection such as osteomyelitis. The procedure involves making an incision, accessing the vertebral body, obtaining a tissue sample, and closing the incision.
Example 1: A patient presents with persistent back pain and radiological findings suggestive of a tumor in the lumbar spine. An open vertebral body biopsy is performed to obtain a tissue sample for diagnosis., A patient with suspected osteomyelitis of the cervical spine undergoes an open vertebral body biopsy to confirm the diagnosis and identify the causative organism., A patient with a history of cancer develops new neurological symptoms, and imaging reveals a possible metastatic lesion in the thoracic spine. An open vertebral body biopsy is performed to determine the nature of the lesion.
Documentation should include the reason for the biopsy, the location of the lesion, the surgical approach, the type and size of the tissue sample obtained, any complications encountered, and the postoperative course.
** This code describes an open biopsy; less invasive procedures like needle biopsies are coded differently. If a sequestrectomy is performed, the appropriate code for that procedure should be reported instead.
- Specialties:Orthopedic Surgery, Neurosurgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center