Q.   Prior to transrectal guided prostate biopsy; my urologist performs a transrectal ultrasound to establish medical necessity to proceed with the prostate biopsy. The CPT® codes billed are transrectal diagnostic ultrasound (CPT® 76872), the sonographic guidance (76942) and prostate biopsy (55700). Some insurance companies are bundling the two ultrasound codes as incidental. Is there something we can do to convince carriers to pay these three codes?

A.  Correct Coding Solutions, Medicare contractor for the National Correct Coding Initiative (NCCI), issued their final decision to bundle CPT code 76942 Ultrasonic guidance for needle placement paired with CPT codes describing diagnostic ultrasound procedures (specific for urology, CPT code 76872 Ultrasound, transrectal). Their decision was issued in a November 17, 2016 letter to the AUA after AUA questioned the contractor’s original edit that was implemented on July 1, 2016. The AUA also had participated on a conference call with the NCCI and Center for Medicare & Medicaid Services (CMS) representatives and requested that the edit be removed stating that these imaging procedures are performed for separate and specific reasons. The AUA believed that the edit would create erroneous denials.  

However, after several attempts by the AUA to change the edit, CMS has updated the 2017 version of the National Correct Coding Initiative Policy Manual with the codes bundled. The following has been posted to the CMS NCCI website stating in Chapter 9 Radiology, Section H General Policy Statements, “Evaluation of an anatomic region and guidance for a needle placement procedure in that anatomic region by the same radiologic modality at the same or different patient encounter(s) on the same date of service are not separately reportable.  For example, a physician should not report a diagnostic ultrasound CPT code and CPT code 76942 (ultrasonic guidance for needle placement...) when performed in the same anatomic region on the same date of service. Physicians should not avoid these edits by requiring patients to have the procedures performed on different dates of service if historically the evaluation of the anatomic region and guidance for needle biopsy procedures were performed on the same date of service."

The AUA is recommending that providers should consider reporting either CPT code 76872 Ultrasound, transrectal; or CPT code 76942 Ultrasonic guidance for needle placement based on the procedure performed and the documentation in the patient’s chart. A modifier should not be used to unbundle this coding scenario as it has been deemed inappropriate coding.

Q.   Before I perform a transrectal ultrasound (TRUS) and biopsy, I inject an anesthetic agent into the prostate. Can I charge for anesthetic injection?

A.   Some urologists are injecting Xylocaine or some other type of local anesthetic into the prostate. The AMA includes "local infiltration, metacarpal/metatarsal/digital block or topical anesthesia" as part of the description of the CPT® Surgical Package Definition. This type of injection would be considered local infiltration. According to the National Correct Coding Initiative, Chapter I, General Correct Coding Policies (page I-26) state: Under the CMS Anesthesia Rules, with limited exceptions, Medicare does not allow separate payment for anesthesia services performed by the physician who also furnishes the medical or surgical service. In this case, payment for the anesthesia service is included in the payment for the medical or surgical procedure. For example, separate payment is not allowed for the physician's performance of local, regional, or most other anesthesia including nerve blocks if the physician also performs the medical or surgical procedure.

Note: There is some controversy on the billing of the nerve block, 64450 Injection, anesthetic agent; other peripheral nerve or branch with a transurethral ultrasound (TRUS) and ultrason guided biopsy. If the urologist is performing a nerve block (injecting a numbing agent into the nerve bundles outside the prostate) on a Medicare patient, they should not bill the CPT® code 64450 with the TRUS with biopsy. Check with the commercial carriers for the peripheral block along with the TRUS and biopsy. Reimbursement will be based on contract agreements and coverage issues with each carrier.

Q.   How do I bill for a transperineal prostate biopsy with mapping instead of a transrectal prostate biopsy?

A.   Use CPT® code 55706 Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including image guidance. 

Q.   The urologist performed a transrectal ultrasound on a patient prior to a 53852 Transurethral needle ablation (TUNA), 53850 Transurethral microwave thermotherapy (TUMT) or 52647 Interstitial laser coagulation (ILC) procedure to determine the size of the prostate. He describes this as a "prostate volume study." How do I code for this?

A.   The performance of a transrectal ultrasound prior to a TUNA is not considered a "prostate volume study." A true prostate volume study includes 5 mm cuts and views. To code for a TRUS prior to TUNA, use CPT® code 76872 Ultrasound, transrectal.

Q.   How should I code for a prostate volume study prior to brachytherapy and the transperineal radioactive seed implant?

A.   When the urologist performs an ultrasound for prostate volume study (to determine prostate size and plan for needle placement of seeds) before the surgery, code this service with CPT® code 76873, Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure).

Q.   How should I code brachytherapy?

A.  

The radiotherapist's services would be billed separately.

Q.   How do I code for minimally invasive prostate procedures?

A.   Use one of the appropriate CPT® codes from the following list:

Q.   How do I bill for Gold seed markers?

A.   Bill both CPT® 55876 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter) prostate (via needle, any approach) single or multiple, and HCPCS code A4648 Tissue marker, implantable, any type, each.

See CMS Payment for Implantable Tissue Markers (HCPCS Code A4648)

Q.   What is included in CPT® code 55866 laparoscopic prostatectomy?

A.   Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistant when performed. Prostatectomy procedures include cytoplasty or cystourethroplasty as a standard of surgical practice. CPT ® 51800 Cytoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck (anterior Y-plasty, vesical fundus resection), any procedure, with or without wedge resection of posterior vesical neck, should not be reported separately with prostatectomy procedures.

Q.   How do I bill for an open radical prostatectomy?

A.  

In addition, when a radical prostatectomy is performed with a radical cystectomy during the same operative session, both procedures may be billed. The CPT® code 55840 or 55845 can be billed with a -51 modifier in addition to the appropriate cystectomy code. (see below)

Use one of the appropriate CPT® codes from the following list of cystectomy procedures as the primary procedure:

If the prostatectomy is done laparoscopic, you would use CPT® code 55866 Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed. If the lymph nodes are removed, use CPT® code 38571 Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy.

If a laparoscopic cystectomy is performed you would need to use an CPT® code 51999 unlisted laparoscopy procedure, bladder and equate the unlisted code to 51570 – cystectomy, complete; (separate procedure).