Urology Coding Alert

Question: One of the physicians in my practice does express prostate massage. When I asked the physician to describe this procedure to me, he explained: A urine sample is taken beforehand. Next, the prostate is massaged and milked through the perineum. Another urine sample is taken. The urine containing expressed prostate secretions is reviewed under a microscope by the physician, then the specimen is sent to an outside lab for culture and specificity. According to the physician, this is done in patients with a diagnosis of prostatitis to determine whether the inflammation is bacterial, non-bacterial, or whether the patient simply has prostatodynia. How should I code this? Would this be billable in addition to an evaluation and management (E/M) visit code, or would it be considered inclusive?

Anonymous Kansas Subscriber

Answer: There is no separate CPT code for express prostate massage. This procedure should be considered inclusive of the E/M visit code. The microscopic exam of the urine by the physician could be separately coded with 81015 (urinalysis; microscopic only).