tci General Surgery Coding Alert - 2014 Issue 8

Reader Question: Define Salivary Biopsy Type

Question: Our surgeon performed a salivary gland biopsy from the left and right. What code should I use, and should I report modifier 50? Ohio Subscriber Answer: You don’t provide enough information to choose a definitive code. CPT® provides two salivary gland biopsy codes, as follows:  42400 — Biopsy of salivary gland; needle 42405 — … incisional. You should use 42400 if your surgeon inserts a large, hollow-bore percutaneous needle (such as Tru-Cut or Menghini) into the salivary gland and obtains small tissue fragments for the purpose of a biopsy. On the other hand, choose 42405 if the...

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