1 code page views remaining today. Guest accounts are limited to 2 daily page views. Register free account to get more views.
Log in Register free account

Official Description

Biopsy, pleura, percutaneous needle

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 32400 refers to a percutaneous needle biopsy of the pleura, which is the thin membrane that covers the lungs and lines the chest cavity. This procedure is performed to collect a tissue sample from the pleura for diagnostic purposes. The process begins with the selection of an appropriate access site on the patient's body, typically on the chest, where the pleura can be accessed safely. Prior to the insertion of the biopsy needle, the skin at the access site is thoroughly cleansed to minimize the risk of infection. A local anesthetic is then administered to numb the area, ensuring that the patient experiences minimal discomfort during the procedure. Following the administration of the anesthetic, a small incision is made to facilitate the insertion of the biopsy needle. The needle is carefully inserted into the pleural space, and its cutting edge is positioned against the pleura to obtain a tissue sample. It is important to note that multiple passes with the needle may be necessary to secure an adequate sample for analysis. This procedure is crucial for diagnosing various conditions affecting the pleura, including infections, tumors, and other pathological processes. The percutaneous approach allows for a minimally invasive method to obtain necessary tissue for further examination, aiding in the accurate diagnosis and management of pleural diseases.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The percutaneous needle biopsy of the pleura, as indicated by CPT® Code 32400, is performed for several specific clinical reasons. These indications include:

  • Suspected Pleural Disease - This procedure is often indicated when there is a suspicion of disease affecting the pleura, such as pleural effusion, pleuritis, or malignancy.
  • Diagnostic Evaluation - It is utilized to obtain tissue samples for histological examination to confirm or rule out conditions such as infections, tumors, or other abnormalities in the pleura.
  • Unexplained Pleural Effusion - When a patient presents with unexplained pleural effusion, a biopsy may be necessary to determine the underlying cause.

2. Procedure

The procedure for a percutaneous needle biopsy of the pleura involves several critical steps to ensure successful tissue acquisition. These steps include:

  • Site Selection - The physician begins by selecting an appropriate site on the chest wall for needle insertion, taking into account the location of the pleural effusion or the area of interest.
  • Skin Preparation - Once the site is selected, the skin is cleansed with an antiseptic solution to reduce the risk of infection at the biopsy site.
  • Administration of Local Anesthetic - A local anesthetic is then injected into the skin and subcutaneous tissue to numb the area, ensuring patient comfort during the procedure.
  • Incision Creation - A small incision is made at the access site to allow for the insertion of the biopsy needle. This incision is typically minimal to reduce tissue trauma.
  • Needle Insertion - The biopsy needle is carefully inserted into the pleural space. The physician ensures that the cutting edge of the needle is positioned against the pleura to facilitate tissue sampling.
  • Tissue Sample Acquisition - The physician may need to make multiple passes with the needle to obtain an adequate tissue sample for analysis. Each pass is performed with precision to maximize the yield of the biopsy.

3. Post-Procedure

After the completion of the percutaneous needle biopsy of the pleura, several post-procedure care steps are typically recommended. Patients are monitored for any immediate complications, such as bleeding or pneumothorax, which is a potential risk associated with the procedure. The biopsy site may be covered with a sterile dressing, and patients are advised to avoid strenuous activities for a short period to allow for proper healing. Follow-up appointments may be scheduled to discuss the results of the biopsy and any further management based on the findings. It is essential for patients to report any unusual symptoms, such as increased pain, difficulty breathing, or signs of infection, to their healthcare provider promptly.

Short Descr NEEDLE BIOPSY CHEST LINING
Medium Descr BIOPSY PLEURA PERCUTANEOUS NEEDLE
Long Descr Biopsy, pleura, percutaneous needle
Status Code Active Code
Global Days 000 - Endoscopic or Minor Procedure
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Hospital Part B services paid through a comprehensive APC
ASC Payment Indicator Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P1G - Major procedure - Other
MUE 2
CCS Clinical Classification 40 - Other diagnostic procedures of respiratory tract and mediastinum

This is a primary code that can be used with these additional add-on codes.

77002 CPT Add On MPFS Status: Active Code APC N ASC N1 Physician Quality Reporting CPT Assistant Article Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure)
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
53 Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
CR Catastrophe/disaster related
GA Waiver of liability statement issued as required by payer policy, individual case
GC This service has been performed in part by a resident under the direction of a teaching physician
GW Service not related to the hospice patient's terminal condition
LT Left side (used to identify procedures performed on the left side of the body)
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
RT Right side (used to identify procedures performed on the right side of the body)
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
X5 Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
Action
Notes
2016-01-01 Changed Code description changed.
Pre-1990 Added Code added.
Code
Description
Code
Description
Code
Description
Code
Description
Code
Description