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Official Description

Biopsy, soft tissue of thigh or knee area; superficial

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 27323 refers to a biopsy procedure performed on the soft tissues of the thigh or knee area, specifically targeting superficial structures. Soft tissues encompass a variety of components, including muscles, tendons, fat, blood vessels, lymph vessels, nerves, and the tissues that surround joints. During this procedure, anesthesia is administered, which may be local, regional, or general, or conscious sedation, depending on the specific site and depth of the biopsy being performed. The process begins with the cleansing of the skin over the biopsy site to minimize the risk of infection. Following this, a precise incision is made, and the tissue is carefully dissected down to the mass or lesion, ensuring that surrounding blood vessels and nerves are protected throughout the procedure. A sample of the tissue is then obtained and sent to a laboratory for histological evaluation, which is reported separately. After the tissue sample is collected, the incision is closed using sutures. It is important to note that for a superficial biopsy, the appropriate code to use is 27323, while for biopsies that involve deeper tissues requiring more extensive dissection, such as those below the muscle fascia (subfascial) or within the muscle itself (intramuscular), the code 27324 should be utilized.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The biopsy procedure coded as CPT® 27323 is indicated for various clinical scenarios where a superficial tissue sample from the thigh or knee area is necessary for diagnostic purposes. The following conditions may warrant this procedure:

  • Suspicion of Tumors - When there is a palpable mass or lesion that raises concern for malignancy or other pathological conditions.
  • Inflammatory Conditions - In cases where there is a need to evaluate inflammatory processes affecting the soft tissues.
  • Infectious Processes - To obtain tissue for microbiological analysis in suspected infections involving the soft tissues.
  • Unexplained Pain or Swelling - When patients present with unexplained symptoms in the thigh or knee area that require further investigation.

2. Procedure

The procedure for a superficial biopsy of the thigh or knee area involves several critical steps to ensure accuracy and patient safety. The following outlines the procedural steps:

  • Preparation and Anesthesia - The procedure begins with the administration of anesthesia, which may be local, regional, or general, depending on the specific requirements of the biopsy site and the depth of the tissue to be sampled. This step is crucial for minimizing discomfort during the procedure.
  • Site Cleansing - Once the anesthesia has taken effect, the skin over the biopsy site is thoroughly cleansed using antiseptic solutions. This is an essential step to reduce the risk of infection at the incision site.
  • Incision and Dissection - A careful incision is made at the designated site, and the tissue is meticulously dissected down to the mass or lesion. During this step, special attention is given to protect surrounding blood vessels and nerves to prevent complications.
  • Tissue Sample Collection - After accessing the lesion, a sample of the tissue is obtained. This sample is critical for subsequent histological evaluation, which will provide insights into the nature of the tissue and any underlying conditions.
  • Closure of Incision - Following the collection of the tissue sample, the incision is closed using sutures. Proper closure is important for promoting healing and minimizing scarring.

3. Post-Procedure

After the biopsy procedure coded as CPT® 27323, patients are typically monitored for any immediate complications, such as excessive bleeding or signs of infection. Instructions for post-procedure care are provided, which may include keeping the biopsy site clean and dry, monitoring for any unusual symptoms, and managing pain with prescribed medications if necessary. Patients are usually advised to avoid strenuous activities for a specified period to allow for proper healing. Follow-up appointments may be scheduled to discuss the results of the histological evaluation and any further management that may be required based on the findings.

Short Descr BIOPSY THIGH SOFT TISSUES
Medium Descr BIOPSY SOFT TISSUE THIGH/KNEE AREA SUPERFICIAL
Long Descr Biopsy, soft tissue of thigh or knee 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 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) 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).
LT Left side (used to identify procedures performed on the left side of the body)
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).
RT Right side (used to identify procedures performed on the right side of the body)
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.
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.
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).
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
X5 Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician
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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2011-01-01 Changed Short description changed.
Pre-1990 Added Code added.
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