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Biopsy of the soft tissue in the shoulder area involves the extraction of a tissue sample from deeper structures within the shoulder, which may include muscles, tendons, fat, blood vessels, lymph vessels, nerves, and the tissues surrounding the joints. This procedure is essential for diagnosing various conditions, including infections, tumors, or other abnormalities present in the soft tissues. The biopsy is performed under local, regional, or general anesthesia, or conscious sedation, depending on the specific site and depth of the biopsy. Prior to the procedure, the area over the intended biopsy site is thoroughly cleansed to minimize the risk of infection. A surgical incision is made, and the surgeon carefully dissects the tissue down to the mass or lesion, ensuring that surrounding blood vessels and nerves are protected during the process. 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 with sutures, completing the procedure. It is important to note that CPT® Code 23065 is used for superficial biopsies, while CPT® Code 23066 is designated for deeper tissue biopsies that 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 a tissue sample is necessary for diagnostic purposes. The following conditions may warrant this procedure:
The procedure for a deep soft tissue biopsy of the shoulder area involves several critical steps to ensure the safe and effective collection of tissue samples. The following outlines the procedural steps:
Post-procedure care for a deep soft tissue biopsy of the shoulder area includes monitoring the patient for any immediate complications, such as excessive bleeding or infection. Patients are typically advised to keep the biopsy site clean and dry, and to follow any specific instructions provided by the healthcare provider regarding wound care. Pain management may be necessary, and patients may be prescribed analgesics to manage discomfort. Follow-up appointments may be scheduled to review the histological results and to assess the healing process. It is important for patients to report any signs of infection, such as increased redness, swelling, or discharge from the incision site, to their healthcare provider promptly.
| Short Descr | BIOPSY SHOULDER TISSUES | Medium Descr | BIOPSY SOFT TISSUE SHOULDER DEEP | Long Descr | Biopsy, soft tissue of shoulder area; deep | Status Code | Active Code | Global Days | 090 - Major Surgery | 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 | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5B - Ambulatory procedures - musculoskeletal | MUE | 2 | CCS Clinical Classification | 159 - Other diagnostic procedures on musculoskeletal system |
| RT | Right side (used to identify procedures performed on the right side of the body) | 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). | GC | This service has been performed in part by a resident under the direction of a teaching physician | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 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. | 74 | Discontinued out-patient hospital/ambulatory surgery center (asc) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53. | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GA | Waiver of liability statement issued as required by payer policy, individual case | LT | Left side (used to identify procedures performed on the left side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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