Anesthesia Coding Alert

Question: What code applies to a prostate exam under anesthesia? The physician did not use instrumentation for the exam.

Michigan Subscriber

Answer: Prostate exams under anesthesia are rare, so try to get more details about the case before coding it. If the physician performed a prostate biopsy, surgical codes 55700 or 55705 for needle or incisional biopsy or 10021 or 10022 for fine needle aspiration biopsy might apply. These all cross to anesthesia code 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified).

If the physician performed a standard prostate exam, the surgical service falls under an unlisted code because this would normally be part of an E/M service. The best choice is 53899 (Unlisted procedure, urinary system). To report anesthesia, submit 00902 (Anesthesia for; anorectal procedure) and append modifier -23 (Unusual anesthesia). Also include documentation to support medical necessity, including the urologist's request for anesthesia during the procedure.