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Urology Coding Alert

Coding Strategies for Biopsy and Orchiectomy

Published on Fri Feb 01, 2002

A diagnosis of testicular cancer is usually made clinically because the tumor feels hard and certain tumor markers are elevated. An orchiectomy is performed based on this clinical judgment. But when a urologist only suspects testicular cancer, he or she must proceed carefully in biopsying the tumor to avoid "seeding" or spreading the cancer cells. For this reason, a biopsy is performed during a surgical session, which may proceed to a total orchiectomy if the biopsy is positive. The coding dilemma lies in how to bill for the surgical work if the biopsy is negative and no orchiectomy is performed.

Orchiectomy after Biopsy

A urologist who diagnoses testicular cancer preoperatively by clinical examination, sonography (76870, Ultrasound, scrotum and contents), and testicular markers (blood test) proceeds to surgery without a biopsy, removing the testicle using an inguinal approach and billing CPT 54530 (Orchiectomy, radical, for tumor; inguinal approach). On the rare occasions that this procedure is performed bilaterally, bill 54530 with modifier -50 (Bilateral procedure).
 
If the urologist questions whether a malignant tumor exists, he or she makes an inguinal incision, frees and partially clamps the spermatic cord, brings the testicle up out of the scrotum, carefully packs the surrounding wound, opens the tunica vaginalis and looks at the testicle. These precautions are necessary to prevent seeding in the event of a malignant tumor.
 
If the lesion appears malignant on clinical inspection, a radical orchiectomy is completed (54530). No biopsy is done. If uncertainty exists, the urologist may perform a biopsy.
 
For example, a patient visits the urologist because he feels something on his testicle. "The urologist feels it too," says Ira G. Keselman, MD, of Shore Urology in Long Branch, N.Y. "The patient has normal blood markers, but an area of calcification." The urologist performs a biopsy after clamping the cord and walling off the surgical field, Keselman says.
 
The urologist sends the specimen to the lab for a stat analysis. If the biopsy is positive, the urologist proceeds to a radical orchiectomy, billing 54530. The urologist should also bill for the biopsy. The needle biopsy (54500, Biopsy of testis, needle [separate procedure]) is not bundled into 54530; the incisional biopsy (54505, Biopsy of testis, incisional [separate procedure]) is. Bill 54505 with modifier -59 (Distinct procedural service) appended, in addition to 54530. The physician should be paid for the biopsy because it was necessary to determine treatment.
 
The reimbursement for needle biopsy (54500) is higher than that for incisional biopsy when performed in the office, yet an incisional biopsy (54505) requires more work, Keselman says. However, needle biopsies are rarely performed, and incisional biopsies are rarely performed in the office. "If you cut the scrotum and its case, you alter the lymphatic drainage, so you can't follow the development of the cancer," he says. Because 54505 is rarely performed in the office, there is no place-of-service differential. Performed in the hospital, 54505 pays much more than 54500.

No Orchiectomy after Needle Biopsy

If the biopsy is benign, the urologist puts the testicle back into the scrotum and closes the wound. Bill 54530 with modifier -52 (Reduced services) to indicate a lesser procedure: an inguinal approach and mobilization of the testicle, without orchiectomy. Also report the biopsy with 54500-51 (Multiple procedures) or 54505-59-51.
 
The purist method for the above scenario is to bill 55899 (Unlisted procedure, male genital system). The difficulty becomes how to set a fee. Reference the work performed to that of 54530 when setting a fee. Code 54530 has 14.57 relative value units (RVUs), compared to 13 for 54550 (Exploration for undescended testis [inguinal or scrotal area]). However, 54530-52 is a better solution than the unlisted-procedure code because it accurately describes the procedure performed and appropriately uses modifier -52.

Do Not Code for Exploration

Some urologists think they should be paid for the "exploration" involved in dissecting and looking for the tumor. Any surgical procedure code, however, includes the exploration, the viewing, the examination, and the preparation of the operative site.
 
Note: Exploring for an undescended testicle (see "Location, Condition Drives Orchiopexy and Hernia Repair" on page 11) is an exception to this rule.
 
Do not use 54550 for the dissection, because that code is defined as an exploration for an undescended testicle, says Nelda Laskey, RHIT, coder with Garden City Medical Clinic in Garden City, Kan. "54550 is not appropriate because this patient did not have an undescended testicle," she says.

Epidermoid Cyst

Sometimes the urologist finds a benign epidermoid cyst that must be removed. He or she removes only the cyst and repairs the testicle. Report 54522 (Orchiectomy, partial). None of the biopsy codes are bundled with 54522. Bill the biopsy code also, if performed, with modifier -51. For the diagnosis, use 186.9 (Malignant neoplasm of testis; other and unspecified testis) if malignant, and 222.0 (Benign neoplasm of male genital organs; testis) if benign. Also report 222.0 for an epidermoid cyst.

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