Urology Coding Alert

A urologist performs a prostatic nodule biopsy to determine if the nodule is benign or malignant. But there is no specific ICD-9 code for a prostatic nodule of malignant "potential," says Michael A. Ferragamo, MD, clinical assistant professor of urology at State University of New York, Stony Brook.

There are only two codes that represent an unknown etiology a prostate nodule that could be either malignant or benign 236.5 (Neoplasm of uncertain behavior of genitourinary organs; prostate) and 239.5 (Neoplasms of unspecified nature; other genitourinary organs). And although 239.5 is the most appropriate, your carrier may reject it and prefer 236.5 or a benign diagnosis code (600.x, Hyperplasia of prostate).

For a prostate biopsy (55700, Biopsy, prostate; needle or punch, single or multiple, any approach), many carriers allow you to use benign prostate nodule codes (600.x) to support medical necessity for the procedure. A prostatic nodule, however, may be a malignant neoplasm (185, Malignant neoplasm of prostate), as determined by the pathologist's analysis of the biopsy specimen.

Two years ago, ICD-9 attempted to clarify the diagnosis codes for these potentially different lesions by increasing the number of codes for benign prostatic disease. But because the prostate nodule codes (600.x) are still defined as benign, ICD-9 still falls short when it comes to codes for prostate biopsies performed for nodules.

For many carriers, certain 600.x codes constitute medical necessity for the biopsy and consequently support reimbursement. Using a benign diagnosis code for a biopsy may not make sense because you clearly don't know the nodule's morphology. "But if that is what the carrier wants you to use, use it," says Sandy Page, CPC, co-owner of Medical Practice Support Services in Denver.

In particular, you should check your local medical review policies (LMRPs) to see if you can use 600.9 (Hyperplasia of prostate, unspecified), Page recommends. "Hyperplasia" means growth, and "unspecified" indicates that it could be benign, malignant or of unknown etiology. Although you could make a case for 600.9 being "potentially malignant," it is a nonspecific code, Ferragamo says.

Before the new codes were added, urologists used benign prostatic hyperplasia to indicate an enlarged prostate. This diagnosis now has the ICD-9 code 600.0 (Hyperplasia of prostate; hypertrophy [benign] of prostate). Also added at the same time were codes 600.1 ( nodular prostate), 600.2 ( benign localized hyperplasia of prostate), 600.3 ( cyst of prostate) and 600.9. These codes represent a series of benign histological and anatomical lesions.

Of the 600.x series, code 600.1 causes the most confusion. According to its ICD-9 definition, it excludes malignant neoplasm of the prostate, so using it to report a lesion being biopsied would be inappropriate. Also, its position in the middle of a benign process series clearly indicates that it refers to a benign prostate nodule. However, some urologists and coders use 600.1 for needle biopsy of the prostate. Denials may follow because some carrier software correctly recognizes 600.1 as a benign process that does not need a biopsy.

To resolve this issue, the physician must document more than "prostate nodule" for a diagnosis other than 600.x to be used. For clarity especially for the coder the physician should indicate the potential malignancy in his or her documentation. If the physician only writes "prostate nodule," the coder may not know to choose 239.5 instead of 600.1.

Code 239.5 is the most appropriate diagnosis to report when a urologist performs a prostate biopsy because will pay for a needle biopsy with 239.5. Instead, some will pay with 236.5, even though it is not appropriate for a urologist to use this code.

Diagnosis code 236.5 is not appropriate for the prostate biopsy because the code refers to "uncertain" rather than "unspecified" lesions. The pathologist, not the urologist, determines if a biopsy result is uncertain. "When the pathologist can't determine whether a tumor is benign or malignant, 236.5 is an appropriate code," says Nelda Laskey, RHIT, coding specialist with Garden City Medical Clinic in Garden City, Kan.

A urologist could use 236.5, however, under certain circumstances. For example, a patient has a prostate nodule, and the urologist performs a needle biopsy (55700) and reports 239.5 as the diagnosis. The pathologist examines the specimen but cannot determine the morphology and reports the procedure with 236.5. The urologist must perform a repeat biopsy so the pathologist can perform another analysis. For the repeat biopsy, the urologist would report 236.5.

As with all coding and reimbursement issues, you should strive to code accurately while conforming to the mandated and software requirements of your payers, Ferragamo says. You should obtain written confirmation from the carrier concerning mandated diagnosis codes for procedures to facilitate correct reporting and prompt reimbursement.