How To Use CPT Code 27041

CPT 27041 describes the procedure for performing a biopsy of the deep subfascial or intramuscular soft tissue in the pelvis and hip area. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 27041?

CPT 27041 is used to describe the biopsy procedure performed on the deep subfascial or intramuscular soft tissue in the pelvis and hip area. This code is used when the provider needs to determine whether the cells in the patient’s tissue sample are malignant, benign, or precancerous.

2. Official Description

The official description of CPT code 27041 is: ‘Biopsy, soft tissue of pelvis and hip area; deep, subfascial or intramuscular.’ This code should be used when the provider performs a biopsy of the deep soft tissue in the pelvis and hip area, below the fascia or within the muscle.

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. An incision is made in the skin over the deep tumor in the patient’s hip or pelvis area.
3. The provider then incises the tumor capsule and removes a sample of the tumor for analysis.
4. The excised tissue sample is sent to the laboratory for further examination.
5. If necessary, the provider may use microdissection techniques to ensure an accurate sample is obtained.
6. The wound area is irrigated and the incision is closed with sutures.

4. Qualifying circumstances

CPT 27041 is performed when the provider needs to biopsy the deep subfascial or intramuscular soft tissue in the pelvis and hip area. This procedure is typically done to determine the nature of the tissue, whether it is benign, malignant, or precancerous. It is important to note that this code is specifically for deep soft tissue biopsies and should not be used for superficial soft tissue biopsies in the same area.

5. When to use CPT code 27041

CPT code 27041 should be used when the provider performs a biopsy of the deep subfascial or intramuscular soft tissue in the pelvis and hip area. It is important to ensure that the biopsy is performed on the deep tissue and not the superficial tissue. If the biopsy is performed on the superficial tissue, CPT code 27040 should be used instead.

6. Documentation requirements

To support a claim for CPT code 27041, the provider must document the following information:

• Patient’s diagnosis and the need for the biopsy
• Specific location of the biopsy in the pelvis and hip area
• Date of the procedure
• Details of the procedure, including the incision, excision of the tissue sample, and closure of the incision
• Any additional techniques used, such as microdissection
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 27041, ensure that the provider is performing a biopsy of the deep subfascial or intramuscular soft tissue in the pelvis and hip area. This code should not be reported with CPT codes 27040 or any other codes that describe superficial soft tissue biopsies in the same area. It is important to follow the specific guidelines provided by the payer to ensure accurate billing and reimbursement.

8. Historical information

CPT code 27041 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A provider performs a deep subfascial biopsy of the soft tissue in the pelvis and hip area to determine the nature of a tumor.
2. During a surgical procedure, the provider performs an intramuscular biopsy of the soft tissue in the hip area to assess the presence of cancer cells.
3. A patient presents with a suspicious mass in the pelvis, and the provider performs a biopsy of the deep subfascial soft tissue to determine if it is malignant or benign.
4. As part of a diagnostic workup, the provider performs a deep subfascial biopsy of the soft tissue in the pelvis and hip area to investigate the cause of the patient’s symptoms.
5. A patient with a history of cancer undergoes a deep subfascial biopsy of the soft tissue in the pelvis and hip area to monitor for any recurrence or metastasis.
6. During a hip replacement surgery, the provider performs a deep subfascial biopsy of the soft tissue in the pelvis and hip area to rule out any underlying malignancy.
7. A patient with unexplained hip pain undergoes a deep subfascial biopsy of the soft tissue in the pelvis and hip area to determine the cause of the pain.
8. As part of a research study, the provider performs a deep subfascial biopsy of the soft tissue in the pelvis and hip area to collect samples for further analysis.
9. A patient with a suspected soft tissue tumor in the pelvis undergoes a deep subfascial biopsy to confirm the diagnosis and determine the appropriate treatment plan.
10. During a surgical procedure, the provider performs an intramuscular biopsy of the soft tissue in the hip area to assess the extent of muscle involvement in a suspected tumor.