2025 CPT code 49180
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Abdomen, Peritoneum, and Omentum Surgery Feed
Percutaneous needle biopsy of an abdominal or retroperitoneal mass.
Modifiers may be applicable depending on the circumstances of the procedure.For example, modifier 26 (professional component) might be used if the physician only performs the professional portion of the procedure and another provider performed the technical component. Modifier 59 may be used if the service is distinct from other services provided on the same day. Modifier 76 is indicated for a repeat procedure by the same physician, and 77 if the repeat is done by a different physician.
The biopsy is medically necessary to determine the nature of the abdominal or retroperitoneal mass, which is crucial for diagnosis, staging, treatment planning, and prognosis. Medical necessity must be supported by clinical findings and imaging studies suggesting the need for tissue confirmation.
The physician is responsible for preparing the patient, administering anesthesia (if necessary), inserting the needle through the abdominal wall into the mass, obtaining the tissue sample, ensuring hemostasis (stopping bleeding), and applying a bandage to the wound. The physician also orders and interprets the laboratory analysis of the tissue sample.
In simple words: The doctor takes a tissue sample from a lump in the belly using a needle. This sample is sent to a lab to check if the lump is cancerous or not.
This CPT code, 49180, represents a percutaneous needle biopsy of an abdominal or retroperitoneal mass.The procedure involves the insertion of a needle through the skin to obtain a tissue sample from a mass located within the abdominal cavity or the retroperitoneal space (the area behind the peritoneum). The obtained tissue sample is then sent to a laboratory for pathological examination to determine the nature of the mass (benign or malignant).
Example 1: A 55-year-old female presents with a palpable abdominal mass.A percutaneous needle biopsy is performed under ultrasound guidance to obtain tissue for pathological analysis. The results are consistent with a benign fibroid., A 70-year-old male with a history of colon cancer presents with a suspicious retroperitoneal mass identified on CT scan. A percutaneous core needle biopsy is performed under CT guidance to determine if the mass is a recurrence of the cancer., A 30-year-old female presents with abdominal pain and a palpable mass. An ultrasound-guided percutaneous needle biopsy is performed and the resulting tissue shows signs of an inflammatory process, not a malignancy.
Detailed medical history, physical examination findings, imaging studies (e.g., ultrasound, CT scan) showing the location and size of the mass, procedure report documenting needle placement, tissue sample collection, and pathology report with histological findings.
** The location of the mass should be accurately documented.If the mass is located in an unusual location, consider the use of modifier XU (Unusual Non-Overlapping Service) for appropriate billing.
- Revenue Code: P6C (Medicare Fee Schedule: MINOR PROCEDURES - OTHER)
- RVU: This information is not available in the provided text.RVUs vary based on geographic location and payer.
- Global Days: This information is not available in the provided text.Global surgical periods vary depending on the specific procedure and payer.
- Payment Status: Active
- Modifier TC rule: Modifier 26 (professional component) may apply if the technical component (the actual biopsy) is performed by a different provider.
- Fee Schedule: This information is not available in the provided text.Fee schedules vary by payer and geographic region.
- Specialties:Surgery, Radiology, Oncology, Gastroenterology
- Place of Service:Office, Hospital (Inpatient and Outpatient), Ambulatory Surgical Center