General Surgery Coding Alert

Many general surgeons have problems getting paid for percutaneous liver biopsies performed at the same time as other abdominal procedures. Although some coders attribute the denials to an undisclosed black box edit, the actual reason more likely is the diagnosis code used to justify the procedure.

The CPT manual contains three codes for liver biopsy. Of these, 47000 (biopsy of liver, needle; percutaneous) and 47100 (biopsy of liver, wedge) should be used when no other abdominal procedure has been performed. Code 47001 (biopsy of liver, needle; percutaneous, when done for indicated purpose at time of other major procedure [list separately in addition to code for primary procedure]) is an add-on code that should be used only when the biopsy is taken at the same time as another (abdominal) procedure.

The percutaneous biopsy is performed when the patient already is undergoing another abdominal procedure, such as a laparoscopy, says Tray Dunaway, MD, a general surgeon in Camden, S.C. When a larger piece of liver is required, the wedge biopsy code should be used.

Coding for an Add-on Biopsy

But when it comes to reimbursement, Medicare has not published guidelines that bundle or edit liver biopsies to other abdominal procedures. What is required, even for add-on codes such as 47001, is a separate diagnosis code that shows the medical necessity for the biopsy because the diagnosis that justifies the primary procedure likely is unrelated to the liver biopsy. Instead, the results from the pathology lab or, if the results are negative, the patients signs and symptoms should be reported and linked to the 47001 on the HCFA 1500 claim form.

When you bill 47001, it means the surgeon already is in the patients abdomen, performing the primary procedure, says Dari Bonner, CPC, CPC-H, CCS-P, a coding and reimbursement specialist for Xact Coding/Reimbursement Consulting Inc. in Port St. Lucie, Fla. The diagnosis code for the primary procedure, however, should not be used for the liver biopsy. Instead, a second diagnosis code is needed to get the liver biopsy claim paid.

For example, the surgeon is performing a partial colectomy (44140) on a patient with colon cancer (153.6, malignant neoplasm of ascending colon). After opening the patient, the surgeon finds that the liver appears abnormal, so a percutaneous liver biopsy (47001) is performed. The liver sample is sent to pathology and returns positive for a carcinoma that has metastasized to the liver (197.7, secondary malignant neoplasm, liver).

Coding a Negative Biopsy

In the above situation, if the only diagnosis code used for both procedures is 153.6, the liver biopsy likely will be denied, Bonner says. The pathology report should be the primary reason for the liver biopsy. If it returns normal, then code the signs and symptoms that prompted the surgeon to take the biopsy for the second diagnosis.

Such signs and symptoms include hepatomegaly (789.1) and abnormal liver function study (794.8). A patient, for example, may see a general surgeon for gall bladder disease. The surgeon may not be convinced that the problem is in the gall bladder and, on opening the patient, checks elsewhere. The gall bladder is removed, but after an abnormal liver scan, the surgeon decides to perform a liver biopsy. Pathology detects no cancer, so 794.8 is the ICD-9 code linked to the 47001 in this case.

Appealing a Denial

If a commercial carrier bundles the biopsy with the primary abdominal procedure even when a second diagnosis is used, the denial should be appealed, and a copy of the relevant portion of the national Correct Coding Initiative (CCI) should be included to indicate that the procedure is not to be bundled and has been denied inappropriately. The CCI also should be used as the basis of an appeal if a wedge biopsy (47100) is bundled inappropriately to another procedure.

Coders should note that code 47001 is used when a liver biopsy is performed as a second abdominal procedure. If the first procedure is, for example, a thoracotomy, 47000 should be used instead.