Summary & Overview
CPT 48100: Open Surgical Biopsy of Pancreatic Lesion
CPT code 48100 represents an open surgical pancreatic biopsy where a surgeon obtains a tissue sample from a pancreatic lesion and sends it for pathologic evaluation. This code captures a discrete operative procedure distinct from less invasive sampling techniques and is relevant for surgical, oncologic, and diagnostic care pathways. Nationally, accurate coding of pancreatic biopsy procedures affects case mix, reimbursement, and clinical documentation tied to cancer diagnosis and management.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The report addresses coverage considerations and typical billing patterns across major commercial insurers and the federal program.
Readers will find a concise clinical and coding overview, expected sites of service and service type, typical modifiers and payer considerations where available, and guidance on how the code fits into surgical and pathology workflows. The publication also summarizes common documentation elements that support use of the code, outlines related clinical contexts for which the procedure is performed, and notes when additional services or global period rules may apply. Data not available in the input is indicated explicitly.
Billing Code Overview
CPT code 48100 describes an open surgical biopsy of the pancreas in which the provider obtains a tissue specimen from a pancreatic lesion and submits it for pathologic evaluation. The procedure uses an open (laparotomy) approach to access the pancreas and remove or sample the lesion.
Service type: Surgical biopsy / specimen collection
Typical site of service: Hospital operating room or other inpatient surgical suite
Clinical & Coding Specifications
Clinical Context
A typical patient is a 58-year-old individual presenting with persistent epigastric pain, unexplained weight loss, and imaging (CT or MRI) showing a suspicious pancreatic mass or focal lesion. After multidisciplinary review, the surgeon plans an open pancreatic biopsy to obtain tissue for pathological evaluation when less invasive sampling (EUS-guided or percutaneous biopsy) is not feasible due to lesion location, prior anatomy, or nondiagnostic prior attempts. The workflow includes preoperative assessment, informed consent for open pancreatic biopsy, general anesthesia, an open abdominal approach (laparotomy), direct exposure of the pancreas, excision or wedge biopsy of the lesion, hemostasis, and sending fresh tissue to pathology (frozen section if intraoperative decision-making is needed, plus permanent sections). Postoperatively the patient is monitored for complications (bleeding, pancreatitis, infection) and pathology results guide further management such as oncologic staging, resection planning, or systemic therapy decisions.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
11 | Normal, uncomplicated service | Use when the procedure is the primary service provided without unusual circumstances. |
22 |