235 Background: Hepatocellular carcinoma (HCC) is one of the few cancers that can be diagnosed based on imaging findings. Although not always mandatory for diagnosis, biopsy (Bx) can confirm HCC and its histologic subtype. We have demonstrated that Bx is associated with worse survival compared to imaging diagnosis in a multivariate analysis. In turn, factors associated with undergoing a Bx diagnosis were examined. Methods: We obtained demographic, diagnostic, and treatment data of 171,013 patients diagnosed with HCC between 2004–2015 from the National Cancer Database. Binary logistic regression examined factors associated with Bx. Variables analyzed included race, sex, age, comorbidity, facility type, insurance, tumor size, presence of metastatic disease, alpha fetoprotein, total bilirubin, year of diagnosis and administration of therapy. Analysis was performed using SPSS v25. Results: We included 160,517 patients for the final analysis. The median age was 62 (18–90), 73.9% were male and 74.1% were white. 11.5% of tumors were 2 cm or smaller and 13.7% of HCC were metastatic. 78,485 (47.7%) underwent Bx. In a multivariate model, black patients (OR 1.093; 95% CI: 1.061-1.126), older patients (OR 1.579; 95% CI 1.537–1.622), larger tumor size (OR 3.208; 95% CI: 3.085–3.335), private (OR 1.129; 95% CI 1.094-1.164) or Medicare insurance (OR 1.056; 95% CI 1.021–1.093), and metastasis at time of diagnosis (OR 1.318; 95% CI 1.275–1.361) were associated with Bx diagnosis. Factors associated with an imaging diagnosis were female (OR 0.964; 95% CI 0.941–0.987), Asian/Pacific Islanders (OR 0.686; 95% CI 0.657–0.717), more comorbidities (OR 0.578; 95% CI 0.559–0.597), treatment at an academic center (OR 0.447; 95% CI 0.436–0.458), hyperbilirubinemia (OR 0.807; 95% CI 0.784-0.831) or elevated AFP (OR 0.571; 95% CI 0.549-0.594). Over the examined study period 2004-2015, imaging diagnosis was increasingly used. Conclusions: Although imaging alone can be adequate to diagnose many cases of HCC, nearly half of the cohort underwent a Bx. Even though diagnosis by imaging was more frequently used in recent years, there were still racial and institutional differences in pattern of care.