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. This has been an issue for many years. Some insurers 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 Template 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. One of the appeal 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. 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. View the AUA Policy & Advocacy Brief article.
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. 55875 - Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy
76965- Ultrasonic guidance for interstitial radioelement application
The radiotherapist’s services would be billed separately.
Q. How do you report the Rezum procedure?
A. To report the Rezum procedure on medical claims, use CPT® code 53852 Transurethral destruction of prostate tissue; by radiofrequency thermotherapy. The Rezum System uses radiofrequency energy to transform sterile water into stored thermal energy in the form of vapor, or steam. This water vapor is convectively delivered directly into the obstructive prostate tissue that causes BPH, where condensation releases enough thermal energy to denature the targeted prostate tissue cells to cause necrosis. The treated tissue is absorbed by the body's natural immune system. It is intended to relieve symptoms, obstruction, and reduce prostate tissue associated with benign prostatic hyperplasia (BPH). It is also indicated for treatment of prostates with hyperplasia of the central zone and/or a median lobe.
Q. How do I code for minimally invasive prostate procedures?
A. Use one of the appropriate CPT® codes from the following list:
|52647||Laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral caliberation and/or dilation, and internal urethrotomy are included if performed) (ILC)|
|52648||Laser vaporization or prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral caliberation and/or dilation, and internal urethrotomy are included if performed) (PVP)|
|52649||Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral caliberation and/or dilation, and internal urethrotomy are included if performed)|
|52450||Transurethral incision of prostate (TUIP)|
|53850||Transurethral destruction of prostate tissue; by microwave thermotherapy (TUMT)|
|53852||Transurethral destruction of prostate tissue; by radiofrequency thermotherapy (TUNA)|
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.
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?
|55840||Prostatectomy, retropubic radical, with or without nerve sparing; or|
|55845||with bilateral pelvic lymphadenectomy, including external iliac, hypogasteric, and obturator nodes|
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:
|51570||Cystectomy, complete; (separate procedure)|
|51590||Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including bowel anastomosis;|
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).