Neurosurgery Coding Alert

Question: Encounter notes indicate that our surgeon took a thoracic spinal bone biopsy. Would this be considered a superficial or deep bone biopsy? Also, what is the difference between a superficial and deep bone biopsy?

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Answer: Your best bet for this biopsy is 20225 (Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur)). Since the notes indicate that the physician biopsied a vertebral body, this would qualify as a deep bone biopsy.

If it were a superficial bone biopsy, you would have chosen 20220 (… superficial (eg, ilium, sternum, spinous process, ribs)).

Here’s a look at the differences between superficial and deep bone biopsies:

Superficial: A superficial bone biopsy is a procedure where a small sample of bone tissue is taken from the outer layer of

the bone. It is typically performed when the area of interest is close to the surface of the bone and the bone target is close to the skin surface. When a surgeon performs this type of biopsy, they typically use a needle or a small incision. Surgeons use superficial bone biopsies to diagnose conditions such as bone infections, bone tumors, or bone fractures.

Deep: A deep bone biopsy involves obtaining a sample of bone tissue from the inner layers of the bone. Surgeons perform these biopsies when the area of interest is deeper within the bone, the target is further from the skin, and they require a more comprehensive analysis. During a deep bone biopsy, a large incision is made to access the bone. Deep bone biopsies are often used to diagnose conditions like bone cancers, osteomyelitis, or certain bone diseases.