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Biopsy Procedures

Q.What is the proper CPT® code for a post-voiding bladder residual ultrasound (PVR)?

A.When performing a post-voiding residual urine ultrasound, use CPT® code 51798, Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging. However, the AUA Coding and Reimbursement Committee has established that no matter which type of ultrasound machine (imaging or non-imaging) is used to perform the diagnostic procedure, if the intent is to obtain a PVR, then use CPT® code 51798.

There are many commercial carriers who do not recognize that CPT® code 51798 has a XXX global and therefore no global period applies. This procedure should be treated as a radiological procedure and be reimbursed in addition to any surgical procedure or E&M service. If denials are made for this reason, append modifier -25, Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service, to the E&M service and appeal the denial. The AUA has developed appeal letters for assistance in asking the carrier to address the denial of the PVR when billed along with the E&M service. Contact the AUA's Coding Hotline at 866-746-4282 (option 2) or download the letter.

Q.Prior to transrectally guided prostate biopsy; my urologist performs a transrectal ultrasound to establish medically 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.This has been an issue for many years. Some insurance carriers continue to bundle the two ultrasound codes. One helpful condition; however, is to make sure each procedure is separately documented. The AUA has established a Transrectal Prostate Ultrasound and Prostate Biopsy Report to capture all the information to establish medical necessity and adequately document the three CPT® codes performed when performing a TRUS and ultrasonic guided prostate biopsy.

The AUA also has a series of letters to assist urology offices with appeals on this type of claim. The letters can be found here. One of the letters developed covers the appropriate use of CPT® codes for transrectal ultrasound and ultrasonic guided prostate biopsy. If your commercial contract specifically excludes the diagnostic ultrasound code, request a modification to your contract.

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.Not on charges to Medicare. 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 state:

G. Anesthesia Service Included in the Surgical Procedure

Under the CMS Anesthesia Rules, Medicare does not allow separate payment for the 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 service. For example, separate payment is not allowed for the surgeon's performance of local, regional, or other anesthesia including nerve blocks if the surgeon also performs the 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 ultrasonically 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 saturation biopsy?

A.See the answer in the June 2012 issue of the Health Policy Brief.

Q.The urologist performed a transrectal ultrasound on a patient prior to a transurethral needle ablation (TUNA), transurethral microwave thermotherapy (TUMT) or 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. There is a CPT® code for a prostate volume study performed prior to brachytherapy treatment. (See next Q&A.) However, to code for a TRUS prior to TUNA, use CPT® code 76872, Transrectal ultrasound, prostate.

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, Echography, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure).

The brachytherapy procedure itself should be coded:

76965 Ultrasonic guidance for interstitial radioelement application
55875 Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy

The radiotherapist’s services would be billed separately.

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