Urology Coding Alert

Prepare to face denials when you report 51795 and 51797 together

If you report codes for transrectal prostate biopsies to Aetna, you've most likely been frustrated by the company's refusal to pay for the ultrasonic studies during the same encounter. You don't have to worry anymore: Aetna has announced it will begin reimbursing for the prostate ultrasounds your urologist performed at the same time as a prostate biopsy.

You Can Now Report Prostate Ultrasound Codes

If your urologist performs a diagnostic ultrasound, then conducts an ultrasound-guided biopsy, you should charge for the diagnostic ultrasound, ultrasound guidance, and needle biopsy, as follows:

• CPT 76872 --Ultrasound, transrectal

• CPT 76942 --Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation

• CPT 55700 --Biopsy, prostate; needle or punch, single or multiple, any approach.

Aetna hasn't paid on all three of these codes together in several years, says Kathy Bruno, billing manager for UroCare Associates of New York in Garden City. The insurer has now agreed to reverse its previous policy and pay for both the ultrasound guidance and the diagnostic ultrasound. In fact, if Aetna has denied for those services between Nov. 16, 2004, and May 14, 2005, you can, and should, resubmit your claim. If you received a denial after May 14, 2005, you should appeal.

Note: If the patient undergoes the ultrasound procedures in a hospital or other facility, you'll need to append modifier 26 (Professional component) to the ultrasound procedure codes. You will charge for the professional component, and the hospital will charge for the technical component.

Medicare and many other carriers do pay for these three codes, Bruno says. In this particular case, she believes that Aetna is trying to align its policies more with Medicare and other major carriers. Be sure to check with individual carriers on their policies.

Be Cautious Reporting 51795 to Smaller Payers
 
In other news, beginning Nov. 11, 2005, Aetna will consider 51795 (Voiding pressure [VP] studies; bladder voiding pressure, any technique) incidental to code 51797 (Voiding pressure [VP] studies; intra-abdominal voiding pressure [AP] [rectal, gastric, intraperitoneal). You will no longer be able to report both codes for the same patient, on the same day. Aetna announced that it considers the intra-abdominal voiding pressure study (51797) and the bladder voiding pressure study (51795) parts of the comprehensive procedure, which you should report with 51797.

Many urology coders disagree with this decision. "We feel that these two codes should be billed separately because these are separate catheters and each catheter is placed in two separate body parts," says Nicole Petersen, CPC, billing representative with Urology of Virginia PC in the Hampton Roads area. Code 51795 represents the procedure when the urologist measures the pressure in the bladder. Code 51797 is appropriate when the physician measures the pressure in the rectum when the patient voids, Peterson says.

Medicare and some other major carriers, such as Blue Cross/Blue Shield, pay on these two codes when they are billed together, Petersen says. Several small insurance carriers are denying these two codes when she reports them together, she says. Be sure to check with your individual carriers to see if you can report both 51795 and 51797 during the same urodynamics session.