Urology Coding Alert

"Some payers deny full reimbursement when a transrectal ultrasound is performed the same day as ultrasound for a needle biopsy and a biopsy of the prostate. Urologists are discovering that some carriers reject the transrectal ultrasound (76872, echography, transrectal) when billed with the other two procedures. But Urology Practice can get paid for all three procedures and should appeal denials for these services, explaining why the transrectal ultrasound was performed. Using a different diagnosis code for the transrectal ultrasound than the codes used for the biopsies may also help urologists obtain full reimbursement.

The transrectal ultrasound is necessary to evaluate the prostate if the patient has an elevated prostate specific antigen or an abnormal digital rectal examination. Because the urologist cannot tell from the ultrasound whether there is a benign or a malignant neoplasm, the biopsy is necessary. But some carriers believe that because the biopsy is going to be done anyway, there is no need for the initial transrectal ultrasound.

This is a long-standing problem. In a 1992 memorandum to the American Urological Association (AUA), the Health Care Financing Administration (HCFA) said that the correct codes to report the utilization of transrectal ultrasound of the prostate in guidance for needle biopsy when both are performed by a urologist are: 76942 and 55700. If the urologist and the radiologist perform the procedure together, HCFA said the urologist should report 55700 (biopsy, prostate; needle or punch, single or multiple, any approach) and the radiologist should bill 76942 (ultrasonic guidance for needle biopsy, radiological supervision and interpretation). But the underlying question is: How should the urologist be reimbursed if a diagnostic ultrasound is performed the same day as an ultrasonically guided needle biopsy? In its 1992 memo, HCFA said the scenario should be coded using 76872, 76942, and 55700.

Absence of National Policy Creates Coding Confusion

But HCFA also noted that because there was no national policy on this, the coverage of these services under Medicare is at the discretion of the carriers. The Correct Coding Initiative (CCI), implemented in 1996, allows these three codes to be billed together, according to the AUA. Carriers are not supposed to create their own coding edits in terms of coverage guidelines put in place by HCFA outside of CCI, although they can set their own policies regarding specific ICD-9 codes and frequency edits.

In a coding communication from the May 1996 CPT Assistant, the American Medical Association reported that it is correct to report 76872, 76942 and 55700 for a prostate needle biopsy with ultrasonic guidance and a separate diagnostic transrectal ultrasound. The CPT Assistant also states: Remember, the use of 76872 does not preclude reporting 76942 ... The intent of code 76872 is to describe a diagnostic transrectal ultrasound. The intent of CPT code 76942 is to describe an ultrasound used to localize a mass or region to be biopsies with a needle, and to guide the needle into the mass or region. By defining the intent of each code, we see that each clearly represents a separate and distinct service.

Using a Different Diagnosis Code

There shouldnt be a problem with billing 76872, 76942 and 55700 on the same day, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding, reimbursement and compliance consulting company based in Denver. But you cant use the same diagnosis code for the TRUS [transrectal ultrasound]. This is because 76872 is a diagnostic code. You can use 600.x (hyperplasia of prostate) for the transrectal ultrasound, but you should use an unspecified neoplasm code, such as 239.5 (neoplasms of unspecified nature, other genitourinary organs), for the ultrasonic guidance for the biopsy and for the biopsy itself.

There is room for disagreement, however. Some coders strongly believe that neoplasm codes should not be used until the biopsy results are back from pathology. Why label a patient, they reason, until you know for sure? Also, they insist that proper coding requires that the pathology report be back before coding for the biopsy procedure itself. This puts urology coders in a difficult position because many payers wont reimburse for a biopsy with a 600 diagnosis code.

In fact, many payers do want separate diagnoses for the transrectal ultrasound and the biopsy and ultrasound guidance. And if there is a different diagnosis, thats fine, says Ray Painter, MD, a urologist who is president of PRS, a coding and compliance consulting company in Denver. This should not be a criterion for payment. There is no requirement anywhere that you need a different diagnosis.

As always, the bottom line here is to check with your payer. Some will not pay for biopsy using 600.x.
The codes involved are 76942, 76872 and 55700."