How To Use CPT Code 27614

CPT 27614 describes the excision of a lesion from the muscle or subfascial tissues of the leg or ankle area for pathological evaluation. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 27614?

CPT 27614 can be used to describe the excision of a lesion from the muscle or subfascial tissues of the leg or ankle area. This code is used when the provider removes a portion or the entirety of suspicious tissue for pathological examination. The procedure helps diagnose the nature of the lesion and determine the appropriate treatment.

2. Official Description

The official description of CPT code 27614 is: ‘Biopsy, soft tissue of leg or ankle area; deep (subfascial or intramuscular).’ This code is used when the provider excises a lesion from the muscle or subfascial tissues of the leg or ankle area for pathological evaluation.

3. Procedure

1. The provider prepares the patient for the procedure, ensuring appropriate prepping and anesthesia.
2. A small incision is made in the skin over the lesion using a sharp instrument.
3. The incision is carried down through the subcutaneous tissue.
4. The provider incises the fascia and removes a small piece of tissue from the muscle or subfascial tissues.
5. The specimen is sent to the lab for pathological evaluation.
6. The provider closes the incision in layers.

4. Qualifying circumstances

CPT 27614 is performed when there is a need to remove a lesion from the muscle or subfascial tissues of the leg or ankle area for pathological evaluation. The procedure is typically done to diagnose the nature of the lesion and determine the appropriate treatment. It is important to note that this code specifically applies to deep (subfascial or intramuscular) biopsies in the leg or ankle area.

5. When to use CPT code 27614

CPT code 27614 should be used when the provider performs a deep biopsy of a lesion in the muscle or subfascial tissues of the leg or ankle area. It is important to ensure that the documentation supports the use of this specific code and that the procedure meets the criteria outlined in the official description.

6. Documentation requirements

To support a claim for CPT 27614, the provider must document the following information:

• Patient’s diagnosis and the need for the biopsy
• Location and size of the lesion
• Details of the procedure, including the incision, removal of tissue, and closure
• Pathological evaluation of the specimen
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 27614, ensure that the procedure meets the criteria outlined in the official description. It is important to use the appropriate code based on the depth of the biopsy and the location of the lesion. Simple or intermediate closure is included in this code, but complex closure, neuroplasty, and adjacent tissue transfer should be reported separately if performed. It is also important to follow any specific guidelines provided by the payer or coding guidelines.

8. Historical information

CPT 27614 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A provider performs a deep biopsy of a suspicious lesion in the muscle of the leg for pathological evaluation.
2. A patient presents with a subfascial mass in the ankle area, and the provider performs a deep biopsy to determine the nature of the lesion.
3. A provider excises a deep intramuscular lesion in the leg for pathological evaluation.
4. A patient has a suspicious soft tissue mass in the ankle area, and the provider performs a deep biopsy to diagnose the condition.
5. A provider removes a deep subfascial lesion in the leg for pathological evaluation.
6. A patient presents with a deep intramuscular mass in the ankle area, and the provider performs a biopsy to determine the appropriate treatment.
7. A provider excises a deep subfascial lesion in the leg for pathological evaluation.
8. A patient has a suspicious soft tissue mass in the ankle area, and the provider performs a deep biopsy to diagnose the condition.
9. A provider removes a deep intramuscular lesion in the leg for pathological evaluation.
10. A patient presents with a deep subfascial mass in the ankle area, and the provider performs a biopsy to determine the appropriate treatment.