Urology Coding Alert
Follow Local Policy for Transrectal Ultrasound
However, payers have different limitations on ultrasound codes being used together. Most have incorporated a catch-22: They will pay for an ultrasound with a diagnosis of prostate cancer, but if you already have the diagnosis, you don't need to perform the biopsy.
Some carriers will cover both ultrasounds on the same day if the first (76872) is clearly diagnostic; others will only cover the needle guidance (76942).
The Evaluation and Biopsy
Typically, a patient is referred to the urologist by a primary care physician for an elevated prostate specific antigen (PSA), says Jan Brunetti, CPC, billing coordinator for Urology Associates in Newport, R.I. For this initial consultation, the urologist codes a consultation (99241-99245) with a diagnosis of elevated PSA (790.93). The patient determines if a biopsy is performed, Brunetti says. "They have a choice between 'watchful waiting' and a biopsy," she says.
If the patient elects to have a biopsy, the next visit is coded 76942 for the ultrasound and 55700 for the biopsy with 236.6 (neoplasm of uncertain behavior of genitourinary organs; other and unspecified male genital organs) linked to both codes, Brunetti says. If you do not own the sonographic equipment, append modifier -26 (professional component) to the guidance code. "We append modifier -26 to the 76942 because another company owns the ultrasound machine," she explains.
Because Brunetti's group does not perform the initial ultrasound, it does not need to bill 76872.
Carrier 'Bundling'
CCI doesn't bundle 76872 and 76942, but Medicare carriers and private payers may still refuse to pay for both, says Morgan Hause, CCS, CCS-P, coding specialist with Urology of Indiana. "No matter what the diagnosis, we can't get paid for both," he says. In fact, urologists in Indiana can only get paid for 76872 with an elevated PSA or prostate cancer. "We can't ever bill 76872 for a nodule," Hause says.
Although a diagnostic ultrasound before a biopsy is usually unpayable, after the biopsy (55700) you can get paid 76872 if the biopsy shows cancer. Urologists use a diagnostic ultrasound of the prostate (76872) in a patient with prostate cancer to see how large the prostate is, Hause says. "If it's too big, they will put the patient on Zoladex or Lupron before proceeding with other treatments."
When billing a private payer for a needle biopsy, determine the payer's policy on 76872 and 76942 before filing the claim, Hause says. If the payer refuses to pay for both, and you file both, the payer will choose the lowest-paying code and deny the other.
LMRP Examples
Most payers cover 76872 for evaluating a patient with abnormal PSA or with a diagnosis of prostate cancer (185). Do not use 76942 for such a service.
The Upstate Medicare Division of Blue Cross and Blue Shield of Western New York covers both 76872 and CPT 76942 on the same date of service. Diagnosis codes that are paid include 185 (malignant neoplasm of prostate), 233.4 (carcinoma in situ of breast and genitourinary system; prostate) and 236.5 (neoplasm of uncertain behavior of genitourinary organs; prostate).
Noridian for Iowa does not allow prostate ultrasound for an enlarged prostate unless there is also a nodule. If the enlargement is asymmetrical, Noridian will cover a diagnostic ultrasound. The carrier will also allow 76872 to evaluate PSA, determine the extent of already-known prostate cancer, and monitor the response to treatment. It will not allow 76872 for V76.9 (special screening for malignant neoplasms; unspecified).
Noridian will cover 76872 with diagnosis codes 185, 198.5 (secondary malignant neoplasm of other specified sites; bone and bone marrow), 198.82 (secondary malignant neoplasm of other specified sites; other specified sites; genital organs), 222.2 (benign neoplasm of male genital organs; prostate), 233.4 (carcinoma in situ of breast and genitourinary system; prostate), 236.5 (neoplasm of uncertain behavior of genitourinary organs; prostate), 790.93 (other nonspecific findings on examination of blood; elevated prostate specific antigen), and V10.46 (personal history of malignant neoplasm; genital organs; prostate).
Noridian will allow 76872, 76942 and 55700 to be billed together if a diagnostic ultrasound is followed by the needle biopsy.
Administar Federal has specific indications for urological use of 76872:
Administar Federal also dictates the ways in which 76872 may be used: 1. diagnostic procedure exclusively (76872) and 2. diagnostic procedure in combination with needle biopsy (76872, 76942 and 55700). However, the policy also says: "When a palpable prostatic nodule is present and an ultrasound guidance for needle biopsy (76942) and a needle biopsy (55700) are indicated, echography (76872) is not separately payable."
Administar Federal's local medical review policy (LMRP), unlike others that group these three codes together, lists specific diagnoses that qualify 76872 for medical necessity. Administar Federal allows urologists to bill for 76872 using diagnosis codes 185, 198.82, 233.4, 236.5, 239.5 (other genitourinary organs), 606.8 (infertility due to extratesticular causes), 608.83 (vascular disorders), 790.93, V10.46 and V71.1 (observation for suspected neoplasm). Screening for asymptomatic patients, confirmation of a known diagnosis, evaluation of benign lesions, and family history of prostate cancer do not qualify.
National Heritage LMRP states that if a urologist schedules a patient for an ultrasonically guided biopsy and performs that procedure, the urologist should use 76942 and 55700. If, however, the patient has a diagnostic ultrasound and it is immediately followed by an ultrasonically guided needle biopsy, the urologist may report 76872, 76942 and 55700.
Finding the Right Diagnosis Codes
If your carrier has an LMRP for 76942, 55700 or 76872, check the covered diagnoses. If the patient does not have one of those diagnoses, but the physician still feels the service is medically necessary, give the patient advance notice that Medicare will not cover the procedure and obtain an advance beneficiary notice (ABN). Fortunately, many Medicare carriers will reimburse for the two ultrasound procedures and the needle biopsy, all performed at the same encounter. Modifier -GA (waiver of liability statement on file) is attached to the HCPCS/CPT code for which the ABN was obtained.
Some will pay with 790.93 as well as 263.5. ICD-9 experts prefer 239.5 as a more accurate code for a prostate nodule. Both 236.5 and 236.6 (other and unspecified male genital organs) presume a previously performed biopsy and therefore would be more appropriate for a re-biopsy. Code 600.0 (hypertrophy [benign] or prostate) is rarely paid. It's too early to say whether carriers will revise their policies to include the new prostate intraepithelial neoplasia (PIN) codes.
If the diagnosis code you use is not included in the list of medical necessity, the coder should go back to the physician and ask: "Is this what you want to use, and if so, can I wait for the pathology report to come back?"
For the visit following the biopsy, use whatever diagnosis the biopsy showed to link to the E/M.
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