CPT® Code 21920

Biopsy of soft tissue of the back or flank involves the removal of a small sample of tissue from the superficial layers of the skin and underlying structures. This procedure is essential for diagnosing various conditions, including infections, tumors, or other abnormalities. The term "soft tissue" encompasses a variety of structures, including muscles, tendons, fat, blood vessels, lymph vessels, nerves, and the tissues surrounding joints. The biopsy is typically performed under local, regional, or general anesthesia, or with conscious sedation, depending on the specific site and depth of the biopsy. Prior to the procedure, the area over the biopsy site is thoroughly cleansed to minimize the risk of infection. A careful incision is made to access the tissue, ensuring that surrounding blood vessels and nerves are protected during the dissection. 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 with sutures to promote proper healing. For superficial biopsies, the appropriate code to use is 21920, while deeper tissue biopsies that require more extensive dissection should be coded as 21925.