Outpatient Facility Coding Alert

Question: Please share if you think that the following note substantiates a diagnostic ultrasound: “Transrectal US/guidance for a needle biopsy/needle biopsy. Technique: ‘Transrectal US was subsequently performed. A lidocaine periprostatic block was performed under US guidance. 12 biopsies of the prostate were subsequently performed in sextant fashion with ultrasound guidance. The patient tolerated this well.’”

Florida Subscriber

Answer: No, this documentation does not support a diagnostic ultrasound.

Here’s why: In order to bill for a diagnostic ultrasound with 76872 (Ultrasound, transrectal) or TRUS, the physician must document the diagnostic results of the ultrasound. These results include but are not limited to prostate density, scanning in transverse and sagittal planes from base to apex, volume measurements, height and width by transverse measurements, length by sagittal measurements, evaluating the symmetry of the prostate and continuity of the prostatic capsule, evaluating the surrounding structures including the bladder, seminal vesicles, ejaculatory ducts, and the median lobe size/protrusion of the prostate gland, and documentation of hypoechoic or hyperechoic areas, etc.

Your doctor only mentioned the ultrasound used for guidance. That code (76942, Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) should also be fully documented and in the chart with the recorded images of the site to be localized. A full description of the localization process should also be included, either reported separately or within the operative report of the procedure for which the guidance is utilized. 

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