Gastroenterology Coding Alert

Question: What CPT^® code do you use if a liver biopsy was performed but no specimen was obtained? The operative report reads “No tissue was obtained. Two passes 16 gauge in diameter were made with the Klastskin needle using ultrasound to mark the site. No biopsies or other specimens were collected for this exam.” There is no reason given as to why a specimen was not obtained.

Dallas Subscriber

Answer: If the liver biopsy is performed individually and not as a part of any other procedure, then you would normally report the CPT^® code 47000 (Biopsy of liver, needle; percutaneous). If the liver biopsy was part of another procedure, then you will have to report +47001 (Biopsy of liver, needle; when done for indicated purpose at time of other major procedure [List separately in addition to code for primary procedure]). The unusual aspect of the case you describe is that a specimen was not obtained.  In other words the full work of the service was not completed.  Since only the liver biopsy was done in the procedure that you have described, you will have to choose 47000 and should append modifier 52 (Reduced Services). This provides a means of reporting reduced services without disturbing the identification of the basic service. Using this modifier does not reduce the allowance to the provider in most cases.

If your clinician used guidance such as ultrasound as is the case in the operative report that you have described in your question, you will have to report this separately using 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation]).