© Copyright 2025 American Medical Association. All rights reserved.
The CPT® Code 27613 refers to a biopsy procedure performed on the soft tissues of the leg or ankle 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 initial step involves cleansing the area over the planned biopsy site to minimize the risk of infection. Following this, a careful incision is made, and the tissue is dissected down to the mass or lesion, with particular attention paid to protecting any underlying blood vessels and nerves. 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 27613, 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 27614 should be utilized.
© Copyright 2025 Coding Ahead. All rights reserved.
The biopsy of soft tissue in the leg or ankle area is indicated for various clinical scenarios where there is a need to obtain a tissue sample for diagnostic purposes. The following conditions may warrant this procedure:
The procedure for a superficial biopsy of the soft tissue in the leg or ankle area involves several key steps, each critical to ensuring the safety and effectiveness of the biopsy:
Post-procedure care following a superficial biopsy of the leg or ankle area typically includes monitoring the patient for any immediate complications, such as excessive bleeding or infection. Patients are often advised to keep the biopsy site clean and dry, and to follow specific instructions regarding wound care. Pain management may be necessary, and patients should be informed about signs of infection or other complications that warrant medical attention. Follow-up appointments may be scheduled to discuss the results of the histological evaluation and to determine any further management based on the findings.
| Short Descr | BIOPSY LOWER LEG SOFT TISSUE | Medium Descr | BIOPSY SOFT TISSUE LEG/ANKLE AREA SUPERFICIAL | Long Descr | Biopsy, soft tissue of leg or ankle 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 | 3 | 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) | 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). | 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). | 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. | LT | Left side (used to identify procedures performed on the left side of the body) | 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.) | 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.) | 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 | CR | Catastrophe/disaster related | 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 | T5 | Right foot, great toe | 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 |
|
Date
|
Action
|
Notes
|
|---|---|---|
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.