Urology Coding Alert

When a urologist wants to look at the prostate via sonography, and then also wants to do a biopsy using sonography for guidance, can both of these procedures be billed? Not really, says Ruth Borrero, assistant billing manager at Urology Associates, an eight-provider practice in Manhasset, N.Y. The first sonography 76872 (echography, transrectal)is done because the patient had an elevated prostate specific antigen (PSA), or has some other signs or symptoms. The second sonography 76942 (ultrasonic guidance for needle biopsy, radiological supervision and interpretation)is done because the urologist saw something on the first sonogram that called for a biopsy, Borrero explains.

Based on the findings from the first sono, the doctor determines whether to do a biopsy, Borrero says. If you know before you do the first sono that youre going to do the biopsy, and an auditor comes in and looks at your notes, theyre going to want the money back for the first sono, she says.

However, 76872 and 76942 are not bundled. There is some confusion about this, because four years ago Medicare had a Correct Coding Initiative (CCI) edit which declared 76872 was a component of 76942, says Thomas A. Kent, CMM, president of Kent Medical Management in Dunkirk, Md. HCFA received so many complaints they had to back off, Kent says. This CCI edit was deleted on the same day it was initiated, so these codes can be billed together. However, some carriers may still be denying the combination. In these cases, Kent recommends that you remind the carrier of the CCI edit deletion. If you do bill both procedures together, Kent recommends using the sign or symptom diagnosis on the 76872, and the positive finding from the diagnostic ultrasound on the 76942.

However, an alternative is to have the patient come back another day for the biopsy. Lets say while youre doing the first sono, you notice an area of the prostate that doesnt look normal, says Borrero. Then you can tell the patient to come back for a biopsy.

Borrero recommends that the diagnosis code for both procedures should be whatever sign or symptom indicated the need for the first sonogram. For the needle biopsy, V71.1 (observation and evaluation for suspected conditions not found; observation for suspected malignant neoplasm) could be used as a secondary diagnosis as well, says Borrero.