General Surgery Coding Alert

If you-re having problems getting your surgeon paid for liver biopsies he performs at the same time as other abdominal procedures, the culprit could be your diagnosis coding. Here's what you need to know to claim the reimbursement you-ve got coming.

When selecting an appropriate CPT code for liver biopsy, first consider: Did the liver biopsy occur alone or at the same time as another abdominal procedure?

If the surgeon performs the biopsy without another major abdominal procedure(s), you will report either 47000 (Biopsy of liver, needle; percutaneous) or 47100 (Biopsy of liver, wedge), depending on whether the surgeon obtains the sample by passing the needle through the abdominal or thoracic wall into the liver (percutaneous), or by open surgical excision (wedge), confirms Carrie Young, CPC, coding unit manager at Springfield Clinic LLC in Springfield, Ill.

Terminology watch: You may also see surgeons document a needle biopsy (47000) as a "needle core" or "core" biopsy, Young advises.

Keep an Eye Out for Imaging

Often, the surgeon will use imaging guidance when introducing a needle to collect a liver specimen (47000). Imaging choices include 76942 (Ultrasonic guidance for needle placement-), 77002 (Fluoroscopic guidance for needle placement-), 77012 (Computed tomography guidance for needle placement-) and 77021 (Magnetic resonance guidance for needle placement-).

If your surgeon dictates and signs the official report for the imaging service, you may be able to report the imaging separately using the appropriate CPT code with modifier 26 (Professional component) appended. Note that in most cases, however, a facility radiologist, rather than the surgeon, will report the imaging service.

Learn more: For additional information on coding for imaging services, see Reader Question "Report Fluoro Codes With Caution," on page 95 of this issue.

If the surgeon performs the liver biopsy at the same time as any other major abdominal surgery, however, you should report add-on 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]).

Note: You will use +47001 only in conjunction with a separate, primary procedure code. The surgeon obtains the liver sample using the cutting needle while he is in the abdominal cavity to perform another procedure.

Special exception: If the surgeon obtains the liver sample using the laparoscope, you should report 47379 (Unlisted laparoscopic procedure, liver), regardless of other circumstances, reminds Tami Atkins, CPC-H, audit review coordinator with Surgical Care Affiliates in Greensboro, NC.

Three More Codes Can Describe Liver Bx.

In addition to 47000, +47001 and 47100, CPT contains three other codes that may describe liver biopsy as part of an overall surgical procedure, Young notes. These include:

- 47561 -- Laparoscopy, surgical; with guided transhepatic cholangiography with biopsy. During this procedure, the surgeon may take tissue samples of one or more intra-abdominal structures, including possibly the liver. Do not report +47001 in addition to 47561.

- 47700 -- Exploration for congenital atresia of bile ducts, without repair, with or without liver biopsy, with or without cholangiography

- 49220 -- Staging laparotomy for Hodgkin's disease or lymphoma (including splenectomy, needle or open biopsies of both liver lobes, possibly also removal of abdominal nodes, abdominal node and/or bone marrow biopsies, ovarian repositioning).

Both 47700 and 49220 include liver biopsy, when performed. Therefore, you should not report +47001 in addition to 47700 or 49220.

When reporting 47001 for a liver biopsy on the same day as a major procedure you must be sure to link the biopsy to its own, separate diagnosis.

Here's why: Whatever diagnosis you link to the primary procedure will establish medical necessity for the primary procedure, but it won't establish medical necessity for that liver biopsy you-re also claiming. The liver biopsy (47001) needs its own diagnosis to explain to the payer why it was required.

"Assigning a separate diagnosis to the liver biopsy is sound coding advice and ensures that you address the issue of medical necessity," Young confirms.

Example: The surgeon performs partial colectomy (44140) for a patient with colon cancer (153.6, Malignant neoplasm of ascending colon). Upon opening the patient, the surgeon finds that the liver appears abnormal and takes a liver sample for biopsy (47001). Pathology confirms that carcinoma has metastasized to the patient's liver.

You would link a diagnosis of 197.7 (Secondary malignant neoplasm, liver) to 47001. The colon cancer diagnosis applies only the colectomy, while the liver cancer diagnosis supports the liver biopsy.

In those cases when the pathology report does not reveal cancer, you should link 47001 to the diagnosis code(s) describing the signs and symptoms -- such as hepatomegaly (789.1) or abnormal liver function study (794.8) -- that prompted the surgeon to obtain the biopsy in the first place.

In other words: Use signs and symptoms to explain to the payer why the procedure was necessary. The pathology report should be the primary reason for the liver biopsy. If the report returns normal (not malignancy), then you should list the signs and symptoms that prompted the surgeon to take the biopsy.

Example: A patient sees a general surgeon for gall bladder disease. The surgeon removes the gall bladder (47600, Cholecystectomy) but, after an abnormal liver scan, also decides to perform a liver biopsy. In this case, pathology detects no abnormality. Therefore, you would link a signs-and-symptoms diagnosis of 794.8 to the 47001 to support medical necessity for the liver biopsy.