20200 v. 20205

[Margaret Roddy]

Looking for opinions on the difference between 20200 (Biopsy, muscle; superficial) and 20205 (Biopsy, muscle; deep).

Do the words "superficial" and "deep" which are integral parts of the code definition refer to the muscle (i.e. biopsy of a superficial muscle like the gastocnemius or a deep muscle like the supraspinatus) or the depth at which the biopsy was obtained from any muscle?

If the latter what would the documentation requirement be to differentiate between a superficial and a deep biopsy of a muscle?

Given that the myofascia has to be opened to access the muscle fibers, does that automatically make every muscle biopsy deep because it is subfascial (the definition given by the 3M coding software)?

Thanks in advance

[FTessaBartels]

Here's the lay description:

The physician secures a sample of tissue from a muscle for biopsy. The physician incises the overlying skin and bluntly dissects to the suspect muscle. The muscle tissue is obtained. Bleeding is controlled and the wound is sutured in layers. Report 20200 if the muscle site sampled is superficial and 20205 if the muscle site sampled is deep.

Hope that helps.

F Tessa Bartels, CPC, CEMC