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Biopsy of the soft tissue in the shoulder area involves the extraction of a small sample of tissue for diagnostic purposes. This procedure targets various soft tissues, which encompass muscles, tendons, fat, blood vessels, lymph vessels, nerves, and the tissues that surround joints. The biopsy is typically performed under local, regional, or general anesthesia, or with conscious sedation, depending on the specific site and depth of the biopsy being conducted. Prior to the biopsy, the skin over the designated area is thoroughly cleansed to minimize the risk of infection. A precise incision is made, allowing the surgeon to carefully dissect the tissue down to the mass or lesion while taking precautions to avoid damaging any nearby blood vessels and nerves. Once the tissue sample is obtained, it is sent to a laboratory for histological evaluation, which is reported separately. After the sample is collected, the incision is closed using sutures. It is important to note that CPT® Code 23065 is designated for superficial biopsies, while CPT® Code 23066 is used for biopsies that involve deeper tissues and require more extensive dissection of the overlying tissues.
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Biopsy of the soft tissue of the shoulder area is indicated for various clinical scenarios where tissue sampling is necessary to diagnose conditions affecting the soft tissues. The following are common indications for performing this procedure:
The procedure for a soft tissue biopsy of the shoulder area involves several critical steps to ensure accurate tissue sampling and patient safety. The following outlines the procedural steps:
Post-procedure care is essential for ensuring proper recovery and minimizing complications. After the biopsy, the patient is monitored for any immediate adverse reactions to anesthesia. Instructions are provided regarding wound care, including keeping the incision site clean and dry. Patients may be advised to avoid strenuous activities for a specified period to allow for healing. Follow-up appointments are typically scheduled to discuss the results of the histological evaluation and to assess the healing process of the biopsy site.
| Short Descr | BIOPSY SHOULDER TISSUES | Medium Descr | BIOPSY SOFT TISSUE SHOULDER SUPERFICIAL | Long Descr | Biopsy, soft tissue of shoulder area; superficial | Status Code | Active Code | Global Days | 010 - Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6B - Minor procedures - musculoskeletal | MUE | 2 | CCS Clinical Classification | 159 - Other diagnostic procedures on musculoskeletal system |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition | LT | Left side (used to identify procedures performed on the left side of the body) | QS | Monitored anesthesia care service | QZ | Crna service: without medical direction by a physician | RT | Right side (used to identify procedures performed on the right side of the body) | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| Pre-1990 | Added | Code added. |
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