Most urologists are intimately aware of the transrectal approach using ultrasonic guidance and a needle biopsy to obtain prostate specimens to diagnose prostate cancer. Another newer approach to obtain prostate biopsy specimens is the transperineal, where a stereotactic grid is placed in front of the perineum, ultrasonic guidance is used and the prostate specimens are obtained using a needle as well. The third is prostate biopsy by incisional approach.
Urologists report transrectal ultrasonic guided prostate biopsy using CPT codes 55700 Biopsy, prostate; needle or punch, single or multiple, any approach and 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation. Commensurate with the biopsy, the urologist may perform a transrectal ultrasound (CPT code 76872) to evaluate the size and symmetry of the prostate and to look for suspicious lesions. Urologists typically removed 12 specimens and send those specimens to pathology for examination to determine the presence of prostate cancer. Some urologists determined that it was necessary on occasion to remove more than twelve cores transrectally due to prostate size, location of a nodule on the prostate, or need to biopsy the transition zone.
The majority of these procedures were performed in the urologist’s office under local anesthesia. Occasionally an anesthetic block by injecting a numbing agent into the nerve bundles outside the prostate (CPT code64450 Injection, anesthetic agent; other peripheral nerve or branch) is performed. For Medicare patients, this nerve block is included in the biopsy procedure. However, many commercial insurers may reimburse this procedure separately. Check with each insurer for their reimbursement policy on nerve blocks.
As of January 2009, a new CPT code55706 Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance became available to report a different approach to obtain prostate biopsy specimen. This procedure used a stereotactic grid or template outside the perineum to map the removed cores to a specific area of the prostate. This procedure is referred to as a transperineal biopsy with mapping. This procedure is only performed in the ambulatory surgical center, or outpatient hospital facility under general anesthesia. The ultrasonic guidance is not reported separately.
Although published peer-reviewed literature have referred to both the transperineal with mapping and transrectal prostate biopsy as “saturation biopsy,” the most important point to remember when reporting the correct code for each of these biopsies is the approach used to obtain the prostate specimens which should be clearly documented in the operative report.
The transrectal approach is billed using CPT 55700 (with appropriate ultrasound CPT codes). The ultrasound probe is inserted into the rectum. The transrectal ultrasound is able to guide the physician to obtain specimens in suspicious area using the biopsy gun. When performing the transrectal biopsy, the template or grid is not used during the transrectal approach. The biopsy cores are then placed in a specimen jar and sent to pathology for examination.
The description of the transperineal biopsy with mapping states that the stereotactic template is positioned over the perineum so that precise and exact coordinates for the biopsy can be taken. The urologist transperineally inserts the needle into the prostate and approximately 35-60 specimens are taken at 5mm intervals through the template and removed.
The indications for transperineal biopsy with mapping include a rising PSA (prostatic specific antigen) with prior negative transrectal biopsy (CPT code 55700 Biopsy, prostate; needle or punch, single or multiple, any approach), history of prostatic intraepithelial neoplasm (PIN) as diagnosed through previous pathology on prior biopsy, history of severe dysplasia or focal acinar proliferation, history of a suspicious areas on prior biopsy, or plan for focal ablation of prostatic carcinoma.
Reporting the pathology examination for prostate biopsy
The pathology examination for the prostate specimens for the transrectal approach should be reported using 88305 Level IV - Surgical pathology, gross and microscopic examination, Prostate, and needle biopsy.
There is no instruction on how many cores should be placed in each specimen jar to the pathologist. However, when there are occasions where a transrectal saturation biopsy has been performed, a practice may receive a denial for a Medically Unnecessary Edit (MUE), an edit that allows a maximum number of units of service under most circumstances. According to instruction from Correct Coding Solutions, Medicare’s MUE Edit contractor, “Medicare contractors adjudicate each line of a claim separately against the MUE value for the code on that line. By adjudicating claims in this fashion, the appropriate use of some modifiers (-59 separate procedure) may bypass an MUE value because the modifier causes the HCPCS/CPT code to appear on separate lines of the claim each adjudicated separately against the MUE value for the code on that line of the claim.” In other words, each line is processed by itself and the appropriate MUE is applied to each line. If a denial is received, it is appropriate to break the number of units of 88305 into separate lines and apply the -59 modifier to the second (or third) line on the claim form.
The Centers for Medicare & Medicaid Services (CMS) have developed HCPCS temporary G codes to report the examination of specimens as a result of a transperineal biopsy with mapping. These are the codes reported by the pathologist. There may be an issue in advising the pathologist that the cores sent for examination are from a transperineal biopsy with mapping. A discussion should be established between the urology practice and the pathologist who will perform the examination to develop a protocol for identification of these specimens from a transperineal biopsy with mapping. Report the appropriate G code depending on the total number of cores or specimens taken from the prostate during the transperineal biopsy with mapping and send to the pathologist for evaluation and examination.
The G codes are:
G0416 Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 1-20 specimens
G0417 Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 21-40 specimens
G0418 Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 41-60 specimens
G0419 Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, greater than 60 specimens
For commercial insurers, reporting of the pathology examination for the prostate specimens for the transperineal approach should be done using 88305 Level IV - Surgical pathology, gross and microscopic examination, prostate, needle biopsy.
Approach is the key to correct coding of prostate biopsy
Again, the emphasis needs to be put on the approach when reporting the appropriate CPT codes for these procedures. The specific approach should be the deciding factor for coding, not the number of specimen cores obtained.