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2025 CPT code 50205

Renal biopsy; by surgical exposure of kidney.

Use 50205 when the kidney is surgically exposed for biopsy. Do not use this code for percutaneous biopsies guided by imaging.

Modifiers may be applicable, for example, if the procedure is bilateral (modifier -50), or for other specific circumstances as defined by CPT modifier guidelines.

Medical necessity must be established by documenting the clinical indication for the biopsy, such as unexplained kidney disease, suspicion of malignancy, or transplant evaluation.Alternative diagnostic approaches and their limitations should be considered.

The physician is responsible for performing the surgical procedure, which includes positioning and preparing the patient, making the incision, exposing the kidney, obtaining the biopsy sample, and ensuring proper post-operative care.

IMPORTANT:For percutaneous renal biopsies with imaging guidance, use 50200. For laparoscopic ablation of renal mass lesion(s), use 50542.

In simple words: This procedure involves surgically accessing the kidney to obtain a small tissue sample for examination under a microscope.It's different from a needle biopsy done through the skin, and it requires a longer recovery time.

This code describes a surgical procedure where the kidney is exposed to obtain a tissue sample for biopsy.The procedure involves making an incision, dissecting through muscle, fat, and fascia to reach the kidney, and then using a needle to collect the tissue sample.This differs from a percutaneous biopsy where a needle is inserted through the skin without surgical exposure of the kidney. The collected sample is then sent for pathological examination.

Example 1: A patient presents with unexplained kidney dysfunction and proteinuria. After non-invasive tests are inconclusive, an open surgical biopsy is performed to obtain a tissue sample for definitive diagnosis., A patient with a kidney transplant experiences declining kidney function. An open biopsy is performed to evaluate for rejection or other complications., A patient has a large renal mass not amenable to percutaneous biopsy. An open biopsy is performed to obtain a tissue sample for diagnosis.

Documentation should include operative report detailing the surgical approach, biopsy technique, tissue sample handling, and any complications. Pre-operative studies and post-operative care should also be documented.

** While an open biopsy is less common than a percutaneous biopsy, specific clinical situations may necessitate this approach.Consult iFrameAI for the most accurate and updated information.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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