Urology Coding Alert

Question: A urology practice is doing radiation therapy for prostate cancer as an office/outpatient procedure. This includes services of a radiation oncologist and a urologist. The urologist codes 55875 to place the needles in the prostate and 76965 for imaging guidance of the needles.

I have heard specific complaints that United Healthcare denies claims that are billed in the office, even though the fee schedule lists 55875 for inpatient and office/outpatient setting. UHC denies the claim for invalid place of service, stating the procedure should be inpatient only. The office staff calls ahead of time and gets prior authorization for the procedure to be performed in the office, but the claim is still denied and must be appealed each time. Any suggestions or advice?

Tennessee Subscriber

Answer: Your insurance carrier (United Healthcare) is allowing CPT^® codes 55875 (Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy) and 76965 (Ultrasonic guidance for interstitial radioelement application) to be performed by the urologist in the office, but apparently is not allowing the insertion of radioactive seeds in-office.

The radioactive materials most likely must be used in a hospital setting in specialized radiation protected suites (OR) by a radiation oncologist, which could be the reason for the denial. Recheck your prior authorizations to determine if the authorization includes both the urologist and oncologist, and the services each supplies in an office setting.