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The CPT® Code 27614 refers to a biopsy procedure performed on the soft tissues of the leg or ankle area, specifically targeting deep tissues that are either subfascial or intramuscular. Soft tissues encompass a variety of structures, including muscles, tendons, fat, blood vessels, lymph vessels, nerves, and the tissues that surround joints. This procedure is typically indicated when there is a need to obtain a tissue sample from deeper layers of the leg or ankle to evaluate for potential pathological conditions. Prior to the biopsy, anesthesia is administered, which may be local, regional, or general, depending on the specific site and depth of the biopsy. The area where the biopsy will be performed is thoroughly cleansed to minimize the risk of infection. A surgical incision is then 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 using sutures. It is important to note that this code is specifically for deep biopsies, and for superficial biopsies, CPT® Code 27613 should be used instead.
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The biopsy procedure coded as CPT® 27614 is indicated for various clinical scenarios where deeper tissue evaluation is necessary. The following conditions may warrant this procedure:
The procedure for a deep biopsy of the soft tissues in the leg or ankle area involves several critical steps to ensure accuracy and safety. The following outlines the procedural steps:
After the biopsy procedure, the patient may be monitored for any immediate complications, such as bleeding or infection. Instructions for post-procedure care typically include keeping the biopsy site clean and dry, monitoring for signs of infection, and managing pain with prescribed medications if necessary. Patients are usually advised to avoid strenuous activities for a specified period to promote healing. Follow-up appointments may be scheduled to discuss the results of the histological evaluation and any further management based on the findings.
| Short Descr | BIOPSY LOWER LEG SOFT TISSUE | Medium Descr | BIOPSY SOFT TISSUE LEG/ANKLE AREA DEEP | Long Descr | Biopsy, soft tissue of leg or ankle area; deep (subfascial or intramuscular) | 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) | 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) | 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). | 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). | 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. | 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.) | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | 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 | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | T7 | Right foot, third digit | 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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