Summary & Overview

CPT 49180: Percutaneous Abdominal Needle Biopsy

CPT code 49180 represents a percutaneous needle biopsy of tissue within or behind the abdominal cavity, performed by inserting a needle through the abdominal wall to obtain a specimen for laboratory analysis. This minimally invasive diagnostic procedure is widely used to characterize abdominal masses and guide further management; it is commonly performed in outpatient surgical suites, ambulatory centers, or inpatient settings depending on patient condition. Nationally, accurate coding for 49180 is important for capturing diagnostic activity, ensuring appropriate site-of-service reporting, and facilitating reimbursement for image- or palpation-guided biopsy services.

Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise review of the code’s clinical scope and typical settings, an outline of common modifiers and coding considerations (where available), and context on how this procedure fits into diagnostic pathways for abdominal masses. The publication also summarizes expected documentation elements and potential billing nuances relevant to hospital and ambulatory surgical claims. Data not available in the input is noted where applicable. This piece is intended for national audiences including coding professionals, hospital billing teams, and clinical leaders seeking a clear operational and policy-focused overview of CPT code 49180.

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Billing Code Overview

CPT code 49180 describes a percutaneous needle biopsy of tissue located within or posterior to the abdominal cavity. The procedure involves inserting a needle through the abdominal wall to obtain a tissue sample, which is then sent to a laboratory for pathological analysis to determine the nature of a mass.

Service type: Image- or palpation-guided percutaneous abdominal wall needle biopsy
Typical site of service: Outpatient procedure area, ambulatory surgical center, or hospital inpatient/unit depending on clinical indication and patient stability

Clinical & Coding Specifications

Clinical Context

A 58-year-old patient presents to the outpatient interventional radiology suite with a new, palpable, and imaging-identified intra-abdominal mass near the liver noted on ultrasound and CT. The clinician discusses risks and benefits and obtains informed consent for an image-guided percutaneous abdominal mass biopsy. Under conscious sedation and ultrasound or CT guidance, a core needle is advanced through the anterior abdominal wall into the lesion. One or more tissue cores are obtained and sent to the pathology laboratory for histologic and immunohistochemical analysis to determine whether the mass represents a primary malignancy, metastatic disease, infection, or benign process. Relevant clinical workflow steps include pre-procedure assessment and informed consent, site marking and imaging review, sterile preparation and local anesthesia, image-guided needle placement, tissue acquisition, specimen labeling and documentation, post-procedure monitoring for complications (bleeding, infection, organ injury), pathology result review, and communication of findings to the referring provider for definitive management planning.

Coding Specifications

Modifier	Description	When to Use
`11`	Physician or other qualified health care professional service	Use when the service represents the usual, expected performance for the provider.
`22`

Taxonomy Code	Specialty	Notes
2080P0201X	Interventional Radiology	Most common specialty performing image-guided percutaneous abdominal biopsies.
207K00000X	General Surgery	Surgeons perform percutaneous or open abdominal biopsies when indicated.
207L00000X	Colon & Rectal Surgery	May perform biopsies for masses involving lower abdomen or pelvic wall.
2085R0205X	Diagnostic Radiology	Radiologists perform image interpretation and image-guided needle placement.

CPT Code	Description	Relationship to This Procedure
`10021`	Fine needle aspiration without imaging guidance	Alternative sampling technique when a cytologic FNA is chosen instead of core biopsy; may be performed prior to or instead of core biopsy.
`10022`	Fine needle aspiration with imaging guidance	Used when imaging guidance is employed for FNA; alternative to core needle biopsy when cytology is appropriate.
`76937`	Ultrasound guidance for percutaneous procedures	Represents real-time ultrasound guidance provided during needle biopsy when ultrasound is used.
`77012`	CT guidance for needle placement (initial localization and imaging)	Used when CT guidance is used to localize and guide the percutaneous biopsy needle.
`77021`	Magnetic resonance guidance for percutaneous procedures	Used when MRI guidance is employed for needle localization and biopsy guidance.
`88172`	Cytopathology, immediate cytologic evaluation	Used if on-site immediate evaluation (rapid on-site assessment, ROSE) of biopsy specimen adequacy is performed by a cytopathologist or trained personnel.

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