Pre-operative Diagnosis: Tumor on muscle of right arm
Post-operative Diagnosis: same
After localized anesthesia, a percutaneous bore needle was used to pierce into the muscle to obtain a biopsy of the muscle tissue. Tissue sample will be sent to pathology. No complications resulted to the patient, and he left the office in good condition.
Select the appropriate CPT and ICD-10-CM codes.

Question

Quizplus · Accepted Answer

The correct CPT code for a biopsy of muscle tissue using a needle is 20206, and the RT modifier indicates that the procedure was performed on the right side. The ICD-10-CM code D49.2 is used for neoplasms of unspecified behavior of bone, soft tissue, and skin, which is appropriate for a tumor on the muscle of the right arm when the behavior of the tumor is not yet determined.

Pre-Operative Diagnosis: Tumor on Muscle of Right Arm