2025 CPT code 23065
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Musculoskeletal System Surgery Feed
Biopsy of superficial soft tissue in the shoulder area.
Modifiers may be applicable in specific clinical scenarios. Examples include: modifier 51 for multiple procedures, modifier 22 for increased procedural services, and modifier 76 for repeat procedures. Refer to the current CPT modifier guidelines for further clarification.
Medical necessity for a superficial soft tissue biopsy is established when there is a clinical indication of a potentially malignant or benign lesion.This may be based on clinical examination, imaging studies, or other diagnostic tests. The information provided by the biopsy is crucial for appropriate diagnosis, staging, treatment planning, and prognosis.
The physician or qualified healthcare professional performs the biopsy, prepares the tissue sample, and submits it for pathological analysis. They are responsible for appropriate patient selection, proper technique execution to minimize complications, and interpretation of biopsy results in the context of the patient's clinical presentation.The physician may delegate tasks such as sample preparation to trained staff.
In simple words: The doctor takes a small sample of tissue from a suspicious area on the shoulder (like a small lump under the skin) to test it for cancer or other problems.
This CPT code encompasses the performance of a biopsy on superficial soft tissue located in the shoulder region.The procedure involves obtaining a tissue sample from a suspicious area, such as a lump immediately beneath the skin, for subsequent pathological examination to detect abnormal or cancerous cells. The biopsy may be excisional, incisional, punch, needle, or open, depending on the clinical context.The procedure includes the necessary dissection and preparation of the tissue sample for submission to the laboratory.
Example 1: A 55-year-old male presents with a 1cm palpable mass in the right shoulder area.The mass is firm, non-tender, and non-mobile.Ultrasound shows a solid mass with mixed echogenicity.A superficial soft tissue biopsy (23065) is performed to obtain a tissue sample for histological examination.The results indicate a benign lipoma., A 30-year-old female presents with a 0.5cm pigmented lesion on her left shoulder. The lesion has irregular borders and shows recent growth.Dermatological examination is suggestive of melanoma. A superficial soft tissue biopsy (23065) is taken and shows malignant melanoma.The patient is referred to oncology for further evaluation and treatment., A 72-year-old male with a history of rheumatoid arthritis presents with a fluctuant tender mass over the left acromion. The mass has been progressively increasing in size and is associated with local pain and limited range of motion.Aspiration was non-diagnostic.A superficial soft tissue biopsy (23065) is performed under local anesthesia to rule out an abscess or infection. The biopsy reveals a chronic inflammatory reaction suggestive of a reactive node.
* Preoperative and postoperative diagnosis* Location and size of the lesion* Description of the biopsy technique (excisional, incisional, etc.)* Number of specimens obtained* Pathology report* Images (if available, such as ultrasound or MRI)* Anesthesia administered and by whom* Informed consent
** This code is for superficial soft tissue biopsies of the shoulder area. Deep biopsies or those involving other anatomical structures require separate codes.Ensure proper documentation for accurate coding and reimbursement.
- Revenue Code: P6B (Minor Procedures - Musculoskeletal)
- Payment Status: Active
- Modifier TC rule: No TC modifier is applicable to 23065.
- Fee Schedule: Data on historical fee schedules is not available for this specific code. Contact your local payer for details.
- Specialties:* Dermatology* General Surgery* Orthopedic Surgery* Plastic Surgery
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center