Radiology Coding Alert

Question: How would I code a CT-guided needle lung biopsy when the radiologist failed to get a specimen? The patient was not able to tolerate the position, so the doctor discontinued the procedure.

Alabama Subscriber

Answer: The procedure itself would be assigned 32405 (biopsy, lung or mediastinum, percutaneous needle) along with guidance code 76360 (computerized tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], radiological supervision and interpretation).

Because the procedure was discontinued, you will need to append a modifier. Most likely, you would assign modifier -53 (discontinued procedure) to 32405 in this instance. CPT notes that modifier -53 is reported when a service or procedure is stopped at the physicians discretion usually when unusual circumstances arise. Although this rarely occurs in radiology practices, -53 may be used if a patient was unable to tolerate the procedure, if the patients well-being was threatened or if it became medically necessary to discontinue the procedure.

In addition, many coding experts recommend adding diagnosis code V64.1 (surgical or other procedure not carried out because of contraindication) or V64.3 (procedure not carried out for other reasons) to explain the use of modifier -53.


You Be The Coder and Reader Questions were answered by Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., an Atlanta-based firm that supports 1,000 radiologists and 350 physicians from other specialty areas.