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Orthopedic Coding Alert

Reader Questions:

Don't Forget Fluoro With Biopsy

Published on Tue Jun 27, 2006

Question: Our surgeon performed a disk biopsy at levels L5 and S1 using a Craig needle under fluoroscopic guidance. Which CPT codes should we report? 

Delaware Subscriber Answer: Assuming that your surgeon biopsied the intravertebral disk (and not the vertebral body itself), you should report 21925 (Biopsy, soft tissue of back or flank; deep).
 
In addition, you should report 76003 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) to represent the surgeon's work performing fluoroscopy.
 
If the physician performed the procedure in a facility, remember to append modifier 26 (Professional component) to 76003.  
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