Orthopedic Coding Alert

Question: How should I determine when to use 20200 (superficial muscle biopsy) rather than 20205 (deep muscle biopsy)? Several of our surgeons perform muscle biopsies, usually of the deltoid or quadriceps muscle, which are identified as superficial anterior muscles. Does this mean we must use the superficial code? Or is the biopsy's depth, as opposed to the muscle's location, the determining factor?

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Answer: In this case, -superficial- vs. -deep- is a product of distance from the surface (for instance, skin is superficial, bone is deep), rather than a description of the muscle (in other words, just because the quadriceps is a -superficial- muscle doesn't mean you can't perform a deep biopsy on it).

Bottom line: The actual muscle the surgeon biopsies (such as biceps, quads, etc.) isn't the issue. Rather it is how much dissection and how many other structures would have to be dealt with to access the biopsy site.

The surgeon's clinical judgment may serve as a guide, but as a general rule, you should choose 20205 (Biopsy, muscle; deep) for tissue obtained deep below the fascia, under another layer of muscle or behind bone, whereas you should choose 20200 (- superficial) for tissue taken just below the surface of the skin or superficially just below the muscle fascia.