Neurosurgery Coding Alert
Reader Question:
Choose 20205 for Paraspinal Muscle Biopsy
Published on Tue Apr 29, 2014
Question: Our surgeon performed a posterior lumbar interbody fusion at L4-L5 on a patient. During the laminectomy for decompression of dura at L4 and L5, a gelatinous tissue in paraspinal muscle was located and this was removed in multiple fragments and sent for pathology. What is the appropriate CPT® code for removal of muscle tissue for biopsy?
New Jersey Subscriber
Answer: You report code 20205 (Biopsy, muscle; deep) as your physician seems to be doing a deep muscle biopsy. You may apply modifier 59 (Distinct procedural service) to identify this as a separate service from harvest of local tissue, which is sometimes considered incidental to the major procedure and therefore bundled with it.
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